ATI RN
ATI Perfusion Quizlet
1. Which information shown in the table below about a patient who has just arrived in the emergency department is most urgent for the nurse to communicate to the healthcare provider?
- A. Heart rate
- B. Platelet count
- C. Abdominal pain
- D. White blood cell count
Correct answer: B
Rationale: The correct answer is B: Platelet count. The platelet count is severely decreased, indicating a risk for spontaneous bleeding, which is a critical condition requiring immediate attention. While heart rate, abdominal pain, and white blood cell count are important, a severely decreased platelet count poses a more imminent threat to the patient's health and requires urgent communication to the healthcare provider. The nurse should prioritize addressing this potentially life-threatening issue to ensure prompt intervention and management.
2. The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient?
- A. Are you taking any oral contraceptives?
- B. Have you been prescribed antiseizure drugs?
- C. Do you take medication containing salicylates?
- D. How long have you been taking antihypertensive drugs?
Correct answer: C
Rationale: The correct answer is C: 'Do you take medication containing salicylates?' Petechiae are tiny, pinpoint, red or purple spots on the skin due to bleeding under the skin. Salicylates, which are found in medications like aspirin, interfere with platelet function and can lead to petechiae and ecchymoses. Asking about salicylate-containing medications is crucial in this situation. Choices A, B, and D are incorrect because they are not directly related to the development of petechiae.
3. The nurse is reviewing laboratory results and notes a patient's activated partial thromboplastin time (aPTT) level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication?
- A. Aspirin
- B. Heparin
- C. Warfarin
- D. Erythropoietin
Correct answer: B
Rationale: The correct answer is B: Heparin. An activated partial thromboplastin time (aPTT) level of 28 seconds indicates a prolonged time, which is associated with heparin administration. Heparin is an anticoagulant medication that affects the intrinsic pathway of the coagulation cascade, leading to an increased aPTT. Aspirin (choice A) affects platelet aggregation and does not directly impact aPTT. Warfarin (choice C) affects the extrinsic pathway of the coagulation cascade and is monitored using the international normalized ratio (INR), not aPTT. Erythropoietin (choice D) is not related to coagulation parameters.
4. An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/µL during chemotherapy is to
- A. check all stools for occult blood
- B. encourage fluids to 3000 mL/day
- C. provide oral hygiene every 2 hours
- D. check the temperature every 4 hours
Correct answer: A
Rationale: The correct answer is to check all stools for occult blood. With a platelet count of 18,000/µL, the patient is at a high risk of spontaneous bleeding. Checking stools for occult blood can help detect any internal bleeding early. Encouraging fluids and providing oral hygiene are important interventions in general, but in this case, monitoring for bleeding takes precedence. Checking the temperature every 4 hours is not directly related to the patient's current condition and platelet count.
5. The health care provider orders a liver and spleen scan for a patient who has been in a motor vehicle crash. Which action should the nurse take before this procedure?
- A. Check for any iodine allergy.
- B. Insert a large-bore IV catheter.
- C. Administer prescribed sedatives.
- D. Assist the patient to a flat position.
Correct answer: D
Rationale: Before a liver and spleen scan, it is essential to assist the patient to a flat position. This position helps obtain clear images of the liver and spleen. Checking for iodine allergy (Choice A) is more relevant for procedures involving contrast dye, not a liver and spleen scan. Inserting a large-bore IV catheter (Choice B) may not be necessary for this specific procedure. Administering sedatives (Choice C) is not typically required for a liver and spleen scan, as the patient needs to remain still during the procedure.
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