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. Which action will the admitting nurse include in the care plan for a patient who has neutropenia?
- A. Avoid intramuscular injections
- B. Check temperature every 4 hours
- C. Omit fruits or vegetables from the diet
- D. Place a 'No Visitors' sign on the door
Correct answer: B
Rationale: The correct answer is B: 'Check temperature every 4 hours.' Neutropenic patients have a weakened immune system due to low levels of neutrophils, which are a type of white blood cell that helps fight infections. Monitoring the patient's temperature every 4 hours is crucial because the earliest sign of infection in a neutropenic patient is often a fever. This allows for early detection of any potential infections. Choices A, C, and D are incorrect because avoiding intramuscular injections, omitting fruits or vegetables from the diet, and placing a 'No Visitors' sign on the door are not specific actions directly related to managing neutropenia or monitoring for signs of infection.
3. A patient's complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding?
- A. Have you had any recent weight loss?
- B. Do you have any history of lung disease?
- C. Have you noticed any dark or bloody stools?
- D. What is your dietary intake of meats and proteins?
Correct answer: B
Rationale: The correct answer is B: "Do you have any history of lung disease?" The elevated hemoglobin and hematocrit levels suggest polycythemia, which can be seen in conditions like chronic obstructive pulmonary disease (COPD). Option A is less relevant as weight loss is not typically associated with these blood count findings. Option C is more indicative of gastrointestinal bleeding rather than a respiratory issue. Option D focuses on dietary factors, which are less likely to cause such significant elevations in hemoglobin and hematocrit levels as seen in this case.
4. A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of
- A. iron.
- B. folic acid.
- C. cobalamin (vitamin B12).
- D. ascorbic acid (vitamin C).
Correct answer: C
Rationale: The correct answer is C: cobalamin (vitamin B12). Methotrexate can lead to a deficiency in cobalamin, resulting in megaloblastic anemia. Therefore, increasing the oral intake of cobalamin is essential to address this deficiency. Choice A, iron, is incorrect because megaloblastic anemia caused by methotrexate is not typically due to iron deficiency. Choice B, folic acid, is also incorrect as methotrexate does not directly cause folic acid deficiency. Choice D, ascorbic acid (vitamin C), is incorrect as it is not directly related to megaloblastic anemia caused by methotrexate; instead, cobalamin is the key vitamin that needs attention.
5. A patient who has immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the healthcare provider before obtaining and administering platelets?
- A. Platelet count is 42,000/µL
- B. Petechiae are present on the chest
- C. Blood pressure (BP) is 94/56 mm Hg
- D. Blood is oozing from the venipuncture site
Correct answer: A
Rationale: The correct answer is A. Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/µL unless the patient is actively bleeding. In this scenario, the platelet count of 42,000/µL is not significantly low to warrant a platelet transfusion without active bleeding. Consulting with the healthcare provider is essential before giving the transfusion to ensure the appropriateness of the treatment. Choices B, C, and D are not directly related to the need for consulting before a platelet transfusion. Petechiae, low blood pressure, and oozing from the venipuncture site are common findings in patients with ITP and may not necessarily contraindicate a platelet transfusion at this platelet count.
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