a nurse is assessing a client who is receiving a blood transfusion which of the following findings should the nurse identify as an indication of a hem a nurse is assessing a client who is receiving a blood transfusion which of the following findings should the nurse identify as an indication of a hem
Logo

Nursing Elites

ATI RN

ATI Exit Exam 2023 Quizlet

1. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should the nurse identify as an indication of a hemolytic transfusion reaction?

Correct answer: A

Rationale: The correct answer is A: Low back pain. Low back pain is a common sign of a hemolytic transfusion reaction, indicating the destruction of red blood cells. This finding requires immediate intervention as it can lead to serious complications such as renal failure. Bradycardia (choice B) is not typically associated with a hemolytic transfusion reaction. Chills (choice C) can be seen in febrile non-hemolytic transfusion reactions. Distended neck veins (choice D) are more indicative of fluid overload rather than a hemolytic reaction.

2. The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery for 2 hours. The client begins to complain of increases abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen distended and bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?

Correct answer: B

Rationale: Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and should notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time.

3. When arterial blood pressure declines, the kidneys secrete a hormone to increase blood pressure and peripheral resistance. What is this hormone called?

Correct answer: A

Rationale: Renin is the correct answer. When arterial blood pressure decreases, the kidneys release renin, which triggers a series of reactions ultimately leading to an increase in blood pressure and peripheral resistance. Antidiuretic hormone (choice B) is involved in water retention, atrial natriuretic hormone (choice C) promotes sodium excretion and lowers blood pressure, and insulin (choice D) regulates glucose metabolism, not blood pressure.

4. A nurse is teaching a client about home care following cataract surgery. Which of the following statements should the nurse include?

Correct answer: A

Rationale: The correct answer is A: 'You should wear a protective eye shield while sleeping.' After cataract surgery, wearing a protective eye shield while sleeping is crucial to prevent accidental injury to the eye. Choice B is incorrect because patients should indeed avoid bending over, but it is not the most important instruction among the options provided. Choice C is incorrect because applying pressure to the eye if pain is felt can be harmful and should not be advised. Choice D is incorrect because patients should not resume wearing their regular glasses immediately post cataract surgery; they should wait until their healthcare provider permits.

5. If learning has occurred in classical conditioning, and the neutral stimulus by itself produces a response similar to the reflexive response, the neutral stimulus is then called a __________.

Correct answer: B

Rationale: In classical conditioning, when a neutral stimulus triggers the reflexive response, it becomes a conditioned stimulus. Therefore, the correct term for the neutral stimulus that now elicits a response is a conditioned stimulus. Choices A, C, and D are incorrect: A neutral response is not a standard term in classical conditioning; a conditioned response is the learned response to the conditioned stimulus, not the neutral stimulus itself; a reinforcer is a stimulus that follows a behavior and increases the likelihood of that behavior happening again, which is not the same as a conditioned stimulus.

Similar Questions

A nurse is teaching the partner of a client who had a stroke about manifestations of dysphagia. Which of the following statements by the client's partner indicates the need for further teaching?
How should a healthcare professional manage a patient with non-compliance to hypertension medication?
A nurse is caring for a client who is receiving oxytocin to augment labor. The client's contractions are occurring every 90 seconds with a duration of 90 seconds. Which of the following actions should the nurse take?
A client is starting Simvastatin. Which of the following information should be included in the teaching?
What information should the nurse include when teaching an adolescent with Crohn disease (CD)?

Access More Features

ATI Basic

  • 50,000 Questions with answers
  • All ATI courses Coverage
    • 30 days access @ $69.99

ATI Basic

  • 50,000 Questions with answers
  • All ATI courses Coverage
    • 90 days access @ $149.99