ATI Advanced Med Surg Final Exam 0924 | Nurselytic

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ATI Advanced Med Surg Final Exam 0924 Questions

Extract:

Nurse's Notes
Client admitted to the unit for a lower GI bleed. Continues to have frequent bloody stools and is scheduled for a lower endoscopy in 4 hr. The client is receiving their fourth unit of packed red blood cells (packed RBCs). Unit of fourth packed RBCS started at a rate of 250 cc/hr. Thirty minutes after the transfusion started, client started reporting dyspnea and restlessness. Crackles auscultated in bilateral lower lobes. oxygen saturation 92% on 2L nasal cannula, and jugular vein distension noted.
Vital Signs
Temperature 37.3" (99.1" F)
Blood pressure 189/90 mm Hg
Pulse rate 100/min
Respiratory rate 28/min


Question 1 of 5

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Action to Take

Administer epinephrine
Administer diphenhydramine
Administer furosemide
Administer an antibiotic

Potential Condition

Transfusion chills associate circulatory overload (TACO)
Anaphylactic reaction
Bacterial reaction
Acute intravascular hemolytic reaction

Parameter to Monitor

intake and output
Decrease infusion rate
Low back pain
Weight

Correct Answer: B,C

Rationale: The client's symptoms are consistent with TACO. Administer furosemide to reduce fluid overload and diphenhydramine for possible mild allergic reaction. Monitor intake and output and weight to assess fluid balance.

Extract:


Question 2 of 5

Correct Answer:

Rationale:

Question 3 of 5

Correct Answer:

Rationale:

Question 4 of 5

Correct Answer:

Rationale:

Question 5 of 5

Correct Answer:

Rationale:

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