ATI RN
ATI Perfusion Quizlet
1. The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the
- A. Schilling test
- B. bilirubin level
- C. gastric analysis
- D. stool occult blood
Correct answer: B
Rationale: The correct answer is B: bilirubin level. Jaundice, characterized by scleral jaundice, is caused by the elevation of bilirubin levels associated with red blood cell hemolysis. Checking the bilirubin level in the laboratory results will help assess the severity of jaundice in the patient. Choices A, C, and D are incorrect because the Schilling test is used to assess vitamin B12 absorption, gastric analysis is used to evaluate gastric function, and stool occult blood is used to detect hidden blood in the stool, which are not directly related to evaluating jaundice in a patient with hemolytic anemia.
2. A patient who has acute myelogenous leukemia develops an absolute neutrophil count of 850/µL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate?
- A. Discuss the need for hospital admission to treat the neutropenia
- B. Teach the patient to administer filgrastim (Neupogen) injections
- C. Plan to discontinue the chemotherapy until the neutropenia resolves
- D. Order a high-efficiency particulate air (HEPA) filter for the patient's home
Correct answer: B
Rationale: The correct answer is B because filgrastim (Neupogen) is a medication used to stimulate the production of neutrophils. Teaching the patient to self-administer these injections can help increase the neutrophil count and reduce the risk of infection. Option A is incorrect as hospital admission may not be necessary if the patient can manage the condition at home. Option C is not ideal as discontinuing chemotherapy can impact the leukemia treatment. Option D is unrelated to managing neutropenia in this scenario.
3. Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first?
- A. A 44-year-old with sickle cell anemia who reports his eyes always look somewhat yellow
- B. A 23-year-old with no previous health problems who has a nontender lump in the axilla
- C. A 50-year-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue
- D. A 19-year-old with hemophilia who wants to learn to self-administer factor VII replacement
Correct answer: B
Rationale: The patient's young age and the presence of a nontender lump in the axilla raise concerns for possible lymphoma, which requires prompt evaluation and treatment. This patient should be seen first to rule out any serious underlying condition. Choice A is less urgent as yellowish eyes in sickle cell anemia may be due to jaundice but not necessarily an acute issue. Choice C, a 50-year-old with chronic fatigue related to early-stage chronic lymphocytic leukemia, is a known condition that can be managed on a routine basis. Choice D, a 19-year-old with hemophilia wanting to self-administer factor VII replacement, is important but less urgent compared to the potential lymphoma presentation in choice B.
4. During a physical assessment, the nurse examines the lymph nodes of a patient. Which assessment finding would be of most concern to the nurse?
- A. A 2-cm nontender supraclavicular node
- B. A 1-cm mobile and nontender axillary node
- C. An inability to palpate any superficial lymph nodes
- D. Firm inguinal nodes in a patient with an infected foot
Correct answer: A
Rationale: The correct answer is A. A 2-cm nontender supraclavicular node is of most concern because enlarged and nontender nodes in this area are highly suggestive of malignancies such as lymphoma. Choice B is less concerning as a 1-cm mobile and nontender axillary node is usually benign. Choice C, an inability to palpate any superficial lymph nodes, could be due to factors like obesity or edema, but it is not necessarily a cause for immediate concern. Choice D, firm inguinal nodes in a patient with an infected foot, may indicate a local reaction to infection rather than a systemic issue related to malignancy.
5. The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)?
- A. Verify the patient identification (ID) according to hospital policy
- B. Obtain the temperature, blood pressure, and pulse before the transfusion
- C. Double-check the product numbers on the PRBCs with the patient ID band
- D. Monitor the patient for shortness of breath or chest pain during the transfusion
Correct answer: B
Rationale: The correct answer is B. Unlicensed assistive personnel (UAP) can obtain the temperature, blood pressure, and pulse before a transfusion as their education includes measurement of vital signs. UAP would then report the vital signs to the registered nurse (RN). Option A is typically a nursing responsibility to ensure patient safety and avoid errors in patient identification. Option C involves cross-checking important details and ensuring accuracy, which is usually performed by nursing staff to prevent errors. Option D requires monitoring for potential adverse reactions during the transfusion, which is a nursing responsibility due to the need for assessment and intervention in case of complications.
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