ATI RN
ATI N120n122 Med Surg Exam Questions
Extract:
Question 1 of 5
Which nursing interventions are appropriate for a nurse administering a blood transfusion? Select All That Apply
Correct Answer: B,C,D,E,F
Rationale: Verifying the client's name and blood type with a second nurse is a critical safety measure to prevent transfusion reactions. Infusing the unit of blood within 4 hours is essential to reduce the risk of bacterial growth. Obtaining baseline vital signs prior to starting the transfusion is important to assess the client's condition. Continuously monitoring the client during the first 15 minutes is vital for detecting any signs of a transfusion reaction. Inserting an 18-gauge intravenous catheter is recommended for blood transfusions. Hanging a bag of D5%NS is incorrect; only normal saline should be used. A 22-gauge catheter is acceptable but not preferred.
Question 2 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.
Question 3 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 4 of 5
A nurse is providing education to a client diagnosed with sickle cell anemia. Which of the following can be anticipated will be a trigger for a sickle cell crisis?
Correct Answer: B
Rationale: Dehydration is a significant trigger for sickle cell crises, as it can lead to increased blood viscosity and sickling of red blood cells. Over-hydration is not a trigger for a sickle cell crisis; in fact, adequate hydration helps prevent sickling of the cells. Non-steroidal anti-inflammatory drugs (NSAIDs) are often used to manage pain associated with sickle cell crises, but they do not trigger a crisis. Vaccinations are important for preventing infections in individuals with sickle cell anemia but are not associated with triggering a sickle cell crisis.
Question 5 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.