ATI LPN
ATI LPN Med Surg Haematology Questions
Extract:
Question 1 of 5
The nurse is caring for a patient receiving treatment for a hemolytic reaction from a mismatched blood transfusion. The nurse understands that this the incompatible blood is causing what?
Correct Answer: D
Rationale: A hemolytic reaction involves the immune system destroying incompatible RBCs, leading to hemolysis. Malformed RBCs, B12 deficiency, and immature RBCs are unrelated to this reaction.
Question 2 of 5
A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: Stopping the transfusion is the priority to prevent further exposure to the allergen causing itching and hives, which indicate an allergic reaction. Other actions follow this step.
Question 3 of 5
A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations?
Correct Answer: D
Rationale: Hypotension is a key sign of an acute hemolytic transfusion reaction due to hemolysis causing shock. Jaw pain, urticaria, and distended neck veins are not typical of this reaction.
Question 4 of 5
A nurse is reinforcing teaching with a client who is to have a bone marrow aspiration and biopsy. The nurse should tell the client that, in addition to the iliac crest, a common site for this procedure is which of the following?
Correct Answer: C
Rationale: The sternum is a common site for bone marrow aspiration in adults due to its accessibility to marrow. The iliac crest is another primary site. The hip is not a precise term for aspiration sites, and the cervical spine and humerus are not typically used due to safety and accessibility concerns.
Question 5 of 5
The nurse is caring for a patient with a platelet count of <20,000/mm3 (150,000-400000). Which of the following precautions should the nurse take in providing care for this patient?
Correct Answer: B
Rationale: With a low platelet count, the patient is at high risk for bleeding. Using a soft toothbrush minimizes the risk of gum injury and bleeding, which is a critical safety measure for thrombocytopenic patients. Reporting fever, while important, does not address bleeding risk directly. Hot liquids and straight razors increase the risk of burns or cuts, which could lead to uncontrollable bleeding.