ATI RN
ATI N120n122 Med Surg Exam Questions
Extract:
Question 1 of 5
The client with sickle cell disease (SCD) has recently been sick and is now experiencing a vaso-occlusive crisis. Which priority interventions should the nurse implement?
Correct Answer: D
Rationale: Maintaining IV fluids, administering pain medications, and providing supplemental oxygen are critical interventions that address the acute needs of the client in crisis, aiming to alleviate pain and improve oxygenation. Encouraging frequent ambulation is not appropriate during a vaso-occlusive crisis, as it can exacerbate pain and further compromise blood flow. While monitoring the RBC count is important, it is not the most immediate intervention during a crisis. Treating the client in an outpatient setting is inappropriate during a vaso-occlusive crisis, which typically requires inpatient care for effective pain management and hydration.
Question 2 of 5
The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select three options that apply.
Correct Answer: A,E,F
Rationale: Ensuring comfortable seating at eye level establishes a non-intimidating environment. Setting the room temperature at a comfortable level ensures physical comfort. Removing distracting objects minimizes potential distractions. Facing a strong light may cause discomfort. A distance of 7 ft is too great for effective communication. Placing a chair across from the nurse's desk creates a formal, potentially intimidating setting.
Question 3 of 5
Which of the following are components of the complete blood count (CBC)? Select all that apply.
Correct Answer: A,C,D,E
Rationale: Hemoglobin level is a key component of the CBC, reflecting the oxygen-carrying capacity of the blood. White blood cell count is included in the CBC and is important for assessing the immune response. Platelet count is also part of the CBC and is essential for evaluating clotting function. Red blood cell count is included in the CBC and is crucial for assessing overall blood health and anemia status. Blood glucose level is not part of the CBC; it is typically measured separately in metabolic panels or glucose tests.
Question 4 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 5 of 5
A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. The client's hemoglobin is at 7 g/dL. Which of the following findings should the nurse expect this client to report?
Correct Answer: B
Rationale: Fatigue is a common symptom in clients with anemia, particularly when hemoglobin levels are low, as there is reduced oxygen delivery to tissues, leading to feelings of weakness and tiredness. Diarrhea is not typically associated with anemia. Hypertension is unlikely; hypotension may be more expected. Bradycardia is not typical; tachycardia is more common.