ATI RN Custom Exams Set 4

ATI RN Custom Exams Set 4 Related

Review ATI RN Custom Exams Set 4 related questions and content

The client diagnosed with thalassemia, a hereditary anemia, is to receive a transfusion of packed RBCs. The cross-match reveals the presence of antibodies that cannot be cross-matched. Which precaution should the nurse implement when initiating the transfusion?

  • A. Start the transfusion at 10-15 mL per hour for 15-30 minutes
  • B. Re-crossmatch the blood until the antibodies are identified
  • C. Have the client sign a permit to receive uncrossmatched blood
  • D. Have the unlicensed nursing assistant stay with the client
Correct Answer: A

Rationale: Starting the transfusion slowly at 10-15 mL per hour for 15-30 minutes is the correct precaution to implement when the cross-match reveals the presence of antibodies that cannot be cross-matched. This allows the nurse to monitor for any adverse reactions due to the presence of antibodies. Re-crossmatching the blood until the antibodies are identified is not practical and may delay the transfusion, potentially compromising the patient's condition. Having the client sign a permit to receive uncrossmatched blood is not the best course of action as the focus should be on ensuring a safe transfusion. Having an unlicensed nursing assistant stay with the client does not address the specific precaution needed to manage a transfusion in the presence of antibodies.

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Where do most peptic ulcers occur?

  • A. Esophagus
  • B. Stomach
  • C. Duodenum
  • D. Jejunum
Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

The client is four hours post-operative abdominal aortic aneurysm repair. Which nursing intervention should be implemented for this client?

  • A. Assist the client in ambulating
  • B. Assess the client's bilateral pedal pulses
  • C. Maintain a continuous IV heparin drip
  • D. Provide clear liquids to the client
Correct Answer: B

Rationale: Assessing the client's bilateral pedal pulses is crucial at this point to monitor the perfusion to the lower extremities after abdominal aortic aneurysm repair surgery. Ambulation (Choice A) may be appropriate but should be guided by the assessment findings. Maintaining a continuous IV heparin drip (Choice C) is not typically indicated post-operatively for this type of surgery. Providing clear liquids (Choice D) may not be suitable immediately after the surgery, as the client needs time to recover before resuming oral intake.

During a physical assessment of a newborn, what finding should the nurse prioritize reporting?

  • A. Head circumference of 40 cm
  • B. Chest circumference of 32 cm
  • C. Acrocyanosis and edema of the scalp
  • D. Heart rate of 160 bpm and respirations of 40/min
Correct Answer: A

Rationale: The correct answer is A because a head circumference of 40 cm is unusually large for a newborn, which may indicate hydrocephalus or other abnormalities. Reporting this finding is crucial for further evaluation and intervention. Choices B, C, and D are not as concerning during a newborn physical assessment. A chest circumference of 32 cm is within the normal range for a newborn. Acrocyanosis and edema of the scalp are common findings in newborns and usually resolve without intervention. While a heart rate of 160 bpm and respirations of 40/min should be monitored, they are not as critical as an unusually large head circumference.

In determining and fulfilling the nursing care needs of the patient, which step involves assessing whether the care provided is appropriate and effective in relation to the patient's current physiological and psychological status?

  • A. Evaluation
  • B. Planning
  • C. Implementation
  • D. Assessment
Correct Answer: A

Rationale: The correct answer is A, 'Evaluation.' Evaluation in nursing involves assessing whether the care provided is appropriate and effective in relation to the patient's current physiological and psychological status. This step helps determine the outcomes of the care provided and if any changes are needed. Choice B, 'Planning,' focuses on developing a plan of care based on the assessment findings. Choice C, 'Implementation,' involves carrying out the plan of care. Choice D, 'Assessment,' is the initial step in the nursing process that involves gathering data about the patient's health status.

The client is four hours post-operative abdominal aortic aneurysm repair. Which nursing intervention should be implemented for this client?

  • A. Assist the client in ambulating
  • B. Assess the client's bilateral pedal pulses
  • C. Maintain a continuous IV heparin drip
  • D. Provide clear liquids to the client
Correct Answer: B

Rationale: Assessing the client's bilateral pedal pulses is essential in this situation as it helps in evaluating the peripheral perfusion and circulation in the lower extremities. This assessment is crucial to detect any signs of decreased blood flow or complications, such as arterial occlusion or thrombosis. Ambulating the client may be important in the postoperative period, but assessing pedal pulses takes priority to ensure adequate perfusion. Maintaining continuous IV heparin drip is not typically indicated immediately post-operatively for an abdominal aortic aneurysm repair, as the risk of bleeding complications may outweigh the benefits. Providing a clear liquid diet is not a priority nursing intervention at this stage, as the focus should be on vascular assessment and postoperative monitoring.

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