ATI RN
ATI 410 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions?
Correct Answer: A
Rationale: Acute hemolytic reactions present with fever, chills, headache, low back pain, tachycardia, and apprehension due to red blood cell destruction, requiring immediate intervention.
Question 2 of 5
A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?
Correct Answer: D
Rationale: A hemolytic reaction involves red blood cell destruction, leading to fever, chills, and red-tinged urine due to hemoglobin in the urine, indicating a serious reaction.
Question 3 of 5
A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects?
Correct Answer: C
Rationale: Myelosuppression can cause thrombocytopenia, increasing bleeding risk, including from gums. Anorexia, diarrhea, and alopecia are chemotherapy side effects but not directly related to myelosuppression.
Question 4 of 5
A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?
Correct Answer: C
Rationale: A baseline temperature is crucial to monitor for febrile reactions during transfusion. A significant rise indicates a reaction requiring intervention. Other data are less immediate.
Question 5 of 5
A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?
Correct Answer: A
Rationale: Burns on the head, neck, and chest pose a high risk for airway obstruction due to swelling and inhalation injury. Ensuring a patent airway is critical for oxygenation and survival, taking precedence over other concerns.