ATI RN
ATI N120n122 Med Surg Exam Questions
Extract:
Question 1 of 5
Select the appropriate treatment for the following transfusion reactions
| Options | Hemolytic reaction | Anaphylactic reaction |
|---|---|---|
| Administer 0.9% sodium chloride | ||
| Send the blood bag back to the blood bank for analysis. | ||
| Stop blood infusion | ||
| Administer epinephrine |
Correct Answer: A,B,C for Hemolytic; C,D,B,A for Anaphylactic
Rationale: For hemolytic reaction: Administer 0.9% sodium chloride to maintain fluid balance and prevent kidney damage, send the blood bag back for analysis to identify the cause, and stop blood infusion to prevent further hemolysis. For anaphylactic reaction: Stop blood infusion to prevent further exposure to the allergen, administer epinephrine to treat the severe allergic reaction, send the blood bag back for analysis, and administer 0.9% sodium chloride to maintain fluid balance.
Question 2 of 5
A nurse is caring for a client who has human immunodeficiency virus (HIV). Which laboratory value should the nurse alert the provider of?
Correct Answer: B
Rationale: A CD4-T-cell count of 180 cells/mm³ is significantly low (normal range: 500 to 1500 cells/mm³) and indicates severe immunosuppression, putting the client at increased risk for opportunistic infections, warranting immediate attention from the provider. A positive Western blot test indicates an HIV diagnosis, which is expected in a client with HIV and does not require urgent intervention. A platelet count of 150,000/mm³ is at the lower end of the normal range and does not typically require immediate intervention unless there are clinical symptoms associated. A WBC count of 5,000/mm³ is within the normal range and does not indicate a need for urgent intervention.
Question 3 of 5
A nurse is caring for a client with iron-deficiency anemia. When teaching the client about nutrition, the nurse should educate the client which of the following foods contains the most amount of iron?
Correct Answer: D
Rationale: Red meat and organ meat are excellent sources of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant sources, making them the best choice for increasing iron intake in clients with iron-deficiency anemia. Milk and cheese, whole grain breads, and fresh fruits are not significant sources of iron.
Question 4 of 5
A nurse is preparing to transfuse a unit of packed red blood cells for a client with severe anemia. The nurse should identify that which of the following interventions will help prevent an acute hemolytic reaction?
Correct Answer: A
Rationale: Ensuring the blood is compatible with the client's blood type is critical in preventing an acute hemolytic reaction, as incompatible blood transfusions can cause serious, potentially life-threatening reactions. Administering the transfusion rapidly can increase the risk of complications and does not prevent hemolytic reactions; transfusions should be given at a safe rate based on the client's condition. Using a blood warmer is not a standard intervention to prevent hemolytic reactions; it's typically used in specific cases such as massive transfusions or hypothermia, but it does not address compatibility. Administering prophylactic antihistamines is not a recommended practice to prevent hemolytic reactions; it is more relevant for preventing allergic reactions associated with transfusions.
Question 5 of 5
Select the appropriate treatment for the following transfusion reactions
| Options | Hemolytic reaction | Anaphylactic reaction |
|---|---|---|
| Administer 0.9% sodium chloride | ||
| Send the blood bag back to the blood bank for analysis. | ||
| Stop blood infusion | ||
| Administer epinephrine |
Correct Answer: A,B,C for Hemolytic; C,D,B,A for Anaphylactic
Rationale: For hemolytic reaction: Administer 0.9% sodium chloride to maintain fluid balance and prevent kidney damage, send the blood bag back for analysis to identify the cause, and stop blood infusion to prevent further hemolysis. For anaphylactic reaction: Stop blood infusion to prevent further exposure to the allergen, administer epinephrine to treat the severe allergic reaction, send the blood bag back for analysis, and administer 0.9% sodium chloride to maintain fluid balance.