Bloody or Not
(ATI) A nurse is preparing to administer a transfusion of 300 ml of pooled platelets for a client who has thrombocytopenia. The nurse should plan to administer the transfusion over which of the following time frames?
A. Within 30 minutes/unit
B. Within 60 minutes/unit
C. Within 2 hours/unit
D. Within 4 hours/unit
What is: A. Within 30 minutes/unit
Platelets are fragile and should be infused as quickly as possible to reduce clumping.
B. Fresh frozen plasma within 30-60 min/unit.
C & D. Unit of whole blood or PRBC’s within 2 to 4 hours
A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?
A. Provide support while holding the clients arms.
B. Lean the client toward the wall.
C. Lowering the client to the ground.
D. Assume a narrow base of support.
What is: C. Lowering the client to the ground.
A. Holding the client’s arm does not allow the nurse to easily support the client.
B. Leaning the client to one side alters the center of gravity, causing distorted balance and making the fall more difficult to control.
D. The nurse should assume a wide base of support.
A nurse is instructing a client who has a new prescription for timolol how to insert eye drops. The nurse should instruct the client to press on which of the following areas to prevent systemic absorption of the medication?
A. Bony orbit
B. Nasolacrimal duct
C. Conjunctival sac
D. Outer canthus
What is: B. Nasolacrimal duct = Pressing on the Nasolacrimal duct it will blocks the lacrimal punctum and prevents systemic absorption of the medication.
A nurse is providing teaching to an assistive personnel (AP) about caring for clients with restraints. Which of the following statements by the AP indicates an understanding of the teaching?
A. I will tie restraints in double knots.
B. I will tie a restraint to the portion of the bed that moves when the head of the bed is moved.
C. I will ensure that restraints fit tightly against the client.
D. I will put four side rails up if a client is confused.
What is: B. I will tie a restraint to the portion of the bed that moves when the head of the bed is moved = Restraints should be tied to the portion of the bed that moves when the head of the bed is raised or lowered.
Rationales:
A. Quick release knots should be used.
C. Restraints should not fit tightly as this may interfere with circulation or ventilation depending on restraint type.
D. Placing four side rails up can cause additional confusion and injury
Which blood test should you be sure to monitor for a client taking HCTZ?
a. Sodium level
b. Potassium level
c. Chloride level
d. Calcium level
What is B. Potassium level
(ATI) A nurse is preparing to transfuse a unit of red packed cells (RPCs) for a client who has severe anemia. Which of the following interventions will prevent an acute hemolytic reaction?
A. Ensure that the client has a patent IV line before obtaining the blood product from the refrigerator.
B. Obtain another nurse to confirm the correct client and the correct blood product with you.
C. Take a complete set of vital signs before beginning the transfusion and periodically during the transfusion.
D. Stay with the client for the first 15 to 30 minutes of the transfusion.
What is: B. = Identifying and matching the correct blood product with the correct client will prevent an acute hemolytic reactions from occurring because the reaction is caused by ABO and Rh incompatibility.
A. Ensuring the client has a patent IV line before obtaining the blood product is important, but will not prevent the client from having a hemolytic reaction.
C. Taking vital signs before and during the blood transfusion will identify a potential hemolytic reaction, but will not prevent one.
D. Staying with the client for the first 15 to 20 minutes of the transfusion can ensure prompt identification and treatment of a hemolytic reaction, but will not prevent one.
A nurse is performing triage for a group of clients following a mass casualty incident (MCI). Which of the following clients should the nurse plan to care for first?
A. A client experiencing a tension pneumothorax.
B. A client who has a closed upper extremity fracture.
C. A client who has full-thickness burns over 80% of his body.
D. A client who has agonal respirations.
What is: A. A client experiencing a tension pneumothorax. Rational: The nurse should classify a client experiencing a tension pneumothorax as immediate. The client should receive priority care based on his respiratory status.
B. Rational: The nurse should recognize that a client who has a closed upper extremity fracture could wait several hours for treatment with little risk of adverse effects.
C. Rational: The nurse should classify a client who partial-thickness to full-thickness burns in excess of 60% of his body as expectant. Health care providers should give the clients in this category comfort measures.
D. Rational: A client who has agonal respirations should be classified as expectant. Health care providers should give clients in this category comfort measures.
A nurse in the post-anesthesia recovery unit is caring for a client who received a nondepolarizing neuromuscular blocking agent and has muscle weakness. The nurse should anticipate a prescription for which of the following medications?
A. Neostigmine
B. Naloxone
C. Dantrolene
D. Vecuronium
What is: A. Neostigmine = is a cholinesterase inhibitor used to reverse the effects of nondepolarizing neuromuscular blockers.
B. Naloxone is used to reverse the effects of opioids.
C. Dantrolene acts on the skeletal muscles to reduce metabolic activity and treat malignant hyperthermia.
D. Vecuronium is an intermediate-acting nondepolarizing neuromuscular blockers & is used as a general anasthetic - induces muscle relaxation for endotrachial intubation, mechanical ventilation.
A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?
A. Ask the x-ray technician to come to the client's room to obtain a portable x-ray.
B. Have the client wear a mask.
C. Notify the x-ray department that the client requires airborne precautions.
D. Wear a filtration mask and gloves during transport.
What is: B. Have the client wear a mask.
When a client who has a communicable disease must leave the room, it is important to protect everyone with whom the client comes in contact. Having the client wear a mask protects others from airborne particles should the client cough.
RAtionales:
A. The client may leave the room, as long as the nurse initiates proper precautions.
C.This is an essential action, however, it does not address the precautions the nurse should take to provide safe transportation.
D.This action protects the nurse, but not others on the way to, and in, the radiology department.
The RN is providing care for a client diagnosed with dehydration and hypovolemic shock. Which order should the RN question?
a. Blood pressure every 15 minutes.
b. Insert an 18-guage IV line.
c. Oxygen a 3 L via nasal cannula.
d. D5W to run at 250 ml/hr.
What is: D. D5W to run at 250 ml/hr.
The client needs IV fluids that are isotonic and will increase intravascular volume, such as normal saline. With D5 W the body rapidly metabolizes the dextrose and the solution becomes hypotonic.
(ATI) A nurse is transfusing a unit of packed red blood cells (PRBCs) for a client who has anemia due to chemotherapy. The client reports a sudden headache and chills. The client’s temperature is 2 degrees F higher than baseline. In addition to notifying the provider, which of the following actions should the nurse take? Select all that apply.
A. Stop the infusion.
B. Place the client in an upright position with feet down.
C. Remove the blood bag and tubing from the IV catheter.
D. Obtain a urine specimen.
E. Infuse dextrose 5% in water through the IV.
What is: A, C, & D
A. Stop the infusion. C. Remove the blood bag and tubing from the IV catheter. & D. Obtain a urine specimen.
B. The nurse should place the client with potential circulatory overload in the upright position with feet down. This client’s manifestations do not indicate circulatory overload.
E. The nurse should only infuse 0.9% sodium chloride until a new prescription is received.
A nurse needs to lift a box in the supply room. Which of the following actions should the nurse take to prevent an injury due to lifting?
A. Keep the box close to the body as possible.
B. Stand with feet close together when lifting.
C. Bend at the waist to pick up the box.
D. Twist when placing the box to the side.
What is: A. Keep the box close to the body as possible. Rationale: Proper body mechanics requires keeping the object as close to the body as possible to keep it closer to the lifter’s center of gravity.
B. Rationale: The nurse should stand with their feet about shoulder length apart for stability.
C. Rationale: The nurse should keep their spine straight and bend at the knees.
D. Rationale: The nurse should pivot to place the box at their side,
A nurse is providing information to a client who has early Parkinson’s disease and a new prescription for pramipexole. The nurse should instruct the client to monitor for which of the following side effects?
A. Hallucinations
B. Increased salvation
C. Diarrhea Constipation
D. Discoloration of urine
What is: A. Hallucinations = Pramipexole can cause hallucinations within 9 months of the initial dose and may require discontinuation.
Rationales:
B. is an adverse effect of cholinesterase inhibitors.
C. is an adverse effect of pramipexole.
D. is an adverse effect of COMT inhibitors.
A nurse is admitting a child who has suspected epiglottitis. Which of the following actions should the nurse take first?
A. Administer 0.9% sodium chloride IV solution.
B. Place the child on droplet precautions.
C. Initiate IV antibiotics.
D. Assist with obtaining an x-ray of the child's neck.
What is: B. Place the child on droplet precautions = 1st place the child on droplet precautions to prevent the spread of infection.
RAtionales:
A. The nurse should administer IV fluids to prevent dehydration, but is not the first action the nurse should take.
C. Antibiotics should be started to treat the infection, but it is not the first action the nurse should take.
D. This is not the first action the nurse should take.
A client is admitted to the unit with a diagnosis of inappropriate antidiuretic hormone secretion (SIADH) syndrome. For which electrolyte abnormality would you be sure to monitor?
a. Hypokalemia
b. Hyperkalemia
c. Hyponatremia
d. Hypernatremia
WHat is: C. Hyponatremia = SIADH causes a relative sodium deficit due to excessive retention of water
(ATI) A nurse is caring for a hospitalized patient who has an activated partial thromboplastin time (aPTT) greater than 1.5 times the reference range. Which of the following blood products should the nurse prepare to infuse?
A. Whole blood
B. Platelets
C. Fresh frozen plasma
D. Packed red blood cells
What is: C. Fresh frozen plasma = indicated for a client who has an elevated aPTT because it replaces coagulation factors and can prevent bleeding.
A. Whole blood is infused in clients who have experienced acute blood loss or who require volume expansion in addition to replacement of red blood cells.
B. Platelets are infused for clients who have severe thrombocytopenia and are not indicated for clients who have an elevated aPTT.
D. PRBC’s are transfused for clients who are severely anemic who do not require extra plasma volume.
A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse see first?
A. A conscious adult client who reports shortness of breath, has a respiratory rate of 24/min, and a capillary refill of less than 2 seconds.
B. An unconscious adult client who has a sucking chest wound, respirations 38/min, and a capillary refill of greater than 2 seconds.
C. A conscious adult client who has a dislocated right shoulder, respiratory rate of 18/min., and a capillary refill of less than 2 seconds.
D. An unconscious adult client who has no respirations, capillary refill greater than 2 seconds, and paramedics have already tried to reposition the airway twice.
What is: B. Rationale: Any adult who has a respiratory rate greater than 30/min requires immediate attention. Additionally the client is unconscious, which constitutes altered mental status.
A. Rationale: The client is conscious and has a respiratory rate and capillary refill that are within acceptable range.
C.Rationale: The client is conscious and has a respiratory rate and capillary refill that are within normal range.
D. Rationale: In a disaster situation, a client who is apneic after repositioning of his airway does not receive priority care because they are not expected to survive.
A nurse is teaching a client who has a new prescription for levodopa/carbidopa for Parkinson’s disease. Which of the following instructions should the nurse include?
A. Increase the intake of protein-rich food.
B. Expect muscle twitching to occur.
C. Take the medications with food.
D. Anticipate relief of manifestations in 24 hours.
What is: C. Take the medications with food = to avoid GI upset.
Rationales:
A. The client should avoid protein-rich foods, which can result in decreased therapeutic effects of levodopa.
B. The client should monitor and report muscle twitching which can indicate toxicity & not just to "Expect muscle twiching to occur"
D. Client should anticipate relief of manifestations could take several weeks.
A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply.)
A. Hold the cane on the right side.
B. Keep two points of support on the floor.
C. Place the cane 38 cm (15 in) in front of the feet before advancing.
D. After advancing the cane, move the weaker leg forward.
E. Advance the stronger leg so that it aligns evenly with the cane.
What is A, B & D
A. CORRECT: The client should hold the cane on the uninjured side to provide support for the injured left leg.
B. CORRECT: The client should keep two points of support on the ground at all times for stability.
D. CORRECT: The client should advance the weaker leg first, followed by the stronger leg.
INCORRECT are C & E
C. T he client should place the cane 15 to 25 cm (6 to 10 in) in front of her feet before advancing.
E. T he client should advance the stronger leg past the cane.
A nurse is collecting data from a client who has hypercalcemia as a result of long term use of glucocorticoids. Which of following findings should the nurse expect? (Select all that apply)
a. Hyperreflexia
b. Confusion
c. Positive Chovstek’s sign
d. Bone Pain
e. Nausea and vomiting
What is: B, D, E
B. confusion and a possible decreases LOC, D. Bone pain, E. N/V and anorexia
Rationales:
A. client would have decreased reflexes
C. indicates hypocalcemia
(ATI) A nurse is assessing a client during a transfusion of a unit of whole blood. The client develops a cough, shortness of breath, elevated blood pressure, and distended neck veins. The nurse should anticipate a prescription for which of the following medications?
A. Epinephrine
B. Lorazepam
C. Furosemide
D. Diphenhydramine
What is: C. Furosemide = prescribed to relieve manifestations of circulatory overload.
A. Epinephrine for anaphylactic shock caused by a severe allergic reaction, but is not indicated for manifestations assessed in this client.
B. Lorazepam for severe anxiety, but is not indicated for the manifestations assessed in this client.
D. Diphenhydramine = histamine blocker = may to treat mild allergic reactions, but is not indicated for manifestations assessed in this client.
A community health nurse is reviewing the levels of disease prevention. Which of the following activities is an example of a tertiary prevention?
A. Providing treatment for clients who have chronic obstructive lung disease.
B. Performing screening for sexually transmitted infections.
C. Administering influenza immunizations at a local health fair.
D. Testing new nurses for exposure to tuberculosis
What is: A. Providing treatment for clients who have chronic obstructive lung disease. Rationale: Tertiary prevention reduces complications and disabilities experienced by clients who already have a medical illness.
B. Rationale: Screening for STIs is an example of primary and secondary prevention.
C. Rationale: Immunizations are an example of primary prevention.
D. Testing new nurses for exposure to tuberculosis is an example of secondary
A nurse is reviewing a new prescription for oxcarbazepine with a female client who has partial seizures. Which of the following instructions should the nurse include? (Select all that apply).
A. “Use caution if given a prescription for a diuretic medication.”
B. “Consider using an alternate form of contraception if you are using oral contraception.”
C. “Chew gum to increase saliva production.”
D. “Avoid driving until you see how the medicine affects you.”
E. “Notify your provider if you develop a skin rash.”
What is: A, B, D, E
A. because of the high risk of hyponatremia when taking oxcarbazepine. B. because oxcarbazepine decreases oral contraceptive levels. D. Should avoid driving if CNS effects of dizziness, drowsiness, and double vision develop. E. notify the provider if a skin rash occurs because life-threatening skin disorders can develop.
Rationale:
C. Chewing gum to increase saliva is not indicated because the medicine does not cause dry mouth.
A nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation. Which of the following responses by the nurse is appropriate?
A. "The newborn might be actively shedding the virus."
B. "The newborn is at risk for developing a TORCH infection."
C. "The child might develop encephalitis, a complication of rubella."
D. "Exposure to rubella will suppress the newborn's immune response."
What is: A. "The newborn might be actively shedding the virus." = Infants born to mothers who have rubella will continue to shed the rubella virus for up to 18 months post-delivery
Rationales:
B. TORCH is an acronym for certain maternal viral infections that can cross the placenta and affect the developing fetus. While rubella is one of the TORCH infections, exposure to one viral infection does not increase the risk of developing another.
C. Newborns exposed to rubella are at an increased risk to develop hearing loss, congenital cataracts, and cardiac abnormalities, but not encephalitis.
D. Exposure to rubella does not effect the newborn’s immune response
A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as risk factors for development of this electrolyte imbalance?
a. Crohn’s disease
b. Postoperative following an appendectomy
c. History of bone cancer
d. Hyperthyroidism
What is: A. Crohn’s disease = This malabsorption disorder places the client at risk for hypocalcemia due to inadequate calcium absorption.
Rationales:
B. thyroidectomy places a client at risk for hypocalcemia due to a possible removal or injury to the parathyroid glands.
C. history of bone cancer increases the client’s risk of hypercalcemia due to the shift of calcium from the bone to ECF.
D. Hyperthyroidism places the client at risk for hypercalcemia due to the shift of calcium to ECF.