ATI RN
Endocrinology Exam
1. A nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion?
- A. Asks the client to both say and spell their full name before starting the blood transfusion
- B. Ensures that another qualified healthcare professional checks the unit before administering
- C. Checks the blood identification numbers with the laboratory technician at the Blood Bank at the time it is dispersed
- D. Ensures that all staff wear appropriate personal protective equipment during the transfusion process
Correct answer: C
Rationale: Ensuring the safety of a blood transfusion is crucial to prevent potential errors or adverse reactions. Checking the blood identification numbers with the laboratory technician at the Blood Bank when the blood is dispersed helps confirm that the correct blood product is being administered to the right patient, reducing the risk of transfusion reactions. The other choices are incorrect because asking the client to say and spell their full name (Choice A) is a part of the identification process but not specific to ensuring the safety of the blood transfusion. While having another qualified healthcare professional check the unit (Choice B) is a good practice, the direct verification with the Blood Bank technician is a more critical step in ensuring the correct blood product is administered. Choice D is irrelevant to ensuring the safety of the blood transfusion as it addresses infection control measures.
2. A nurse is caring for several clients with dehydration. The nurse assesses the client with which finding as needing oxygen therapy?
- A. Tenting of skin on the back of the hand
- B. Increased urine osmolarity
- C. Weight loss of 10 pounds
- D. Pulse rate of 115 beats/min
Correct answer: D
Rationale: The correct answer is the pulse rate of 115 beats/min. A rapid pulse rate is a sign of compensatory mechanisms in response to dehydration, indicating that the body is trying to deliver oxygen more efficiently. Oxygen therapy may be needed to support the increased oxygen demand. Tenting of skin on the back of the hand is a classic sign of dehydration due to decreased skin turgor. Increased urine osmolarity and weight loss are also indicators of dehydration, but they do not directly suggest a need for oxygen therapy.
3. A client is receiving an IV infusion of an antibiotic. The client calls the nurse feeling uneasy due to congestion. Which action by the nurse is most appropriate?
- A. Elevate the head of the client's bed to 45 degrees
- B. Have another nurse call the Rapid Response Team
- C. Prepare to administer diphenhydramine (Benadryl)
- D. Slow the rate of the IV infusion
Correct answer: B
Rationale: In this situation, the client's symptoms of congestion and feeling uneasy may indicate an anaphylactic reaction, which can be life-threatening. The most appropriate action is to call the Rapid Response Team to provide immediate assistance and interventions. Elevating the head of the bed, administering diphenhydramine, or slowing the IV infusion rate are not the priority actions in the case of a potential severe allergic reaction. These interventions may delay necessary emergency care and potentially worsen the client's condition.
4. The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse's priority?
- A. Document the observation in the chart.
- B. Measure urine specific gravity and volume.
- C. Assess the pulse and blood pressure.
- D. Assess the client's deep tendon reflexes.
Correct answer: C
Rationale: The correct answer is to assess the pulse and blood pressure. Distended neck veins can indicate fluid volume overload or heart failure, which can lead to hemodynamic instability. Assessing the pulse and blood pressure will provide immediate information on the client's cardiovascular status. Documenting the observation in the chart (choice A) is important but not the priority when immediate assessment is needed. Measuring urine specific gravity and volume (choice B) is important for assessing renal function but is not the priority in this situation. Assessing the client's deep tendon reflexes (choice D) is not relevant to addressing distended neck veins in a client sitting to eat.
5. How does the nurse interpret the client's actions of combing her hair only on the right side of her head and washing only the right side of her face after a stroke?
- A. Poor left-sided motor control
- B. Paralysis or contractures on the right side
- C. Limited visual perception of the left fields
- D. Unawareness of the existence of her left side
Correct answer: D
Rationale: The client's selective grooming and washing habits indicate a condition known as 'unawareness of the existence of her left side,' also called hemispatial neglect. This condition is characterized by a lack of awareness or attention to one side of the body or space, typically the left side in stroke patients. Choices A, B, and C are incorrect because the client's actions are not due to poor motor control, paralysis, contractures, or limited visual perception. Instead, they are indicative of a specific cognitive deficit related to neglecting one side of the body.
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