a nurse is caring for a client who is to receive a transfusion of packed rbcs which of the following actions should the nurse take
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Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam

1. A client is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?

Correct answer: A

Rationale: Prior to administering a blood transfusion, it is essential to prime the IV tubing with 0.9% sodium chloride to prevent hemolysis of the blood cells. Using a smaller gauge IV catheter (e.g., 20 or 22 gauge) is recommended for blood transfusions to prevent hemolysis. Filterless IV tubing is contraindicated for blood transfusions as it does not have a filter to trap potential blood clots or debris. Warming blood is unnecessary and could lead to the development of bacteria in the blood product. Therefore, the correct action for the nurse to take is to prime the IV tubing with 0.9% sodium chloride.

2. Which of the following parameters should be checked when assessing respirations?

Correct answer: D

Rationale: When assessing respirations, it is essential to evaluate the rate at which breaths are taken, the rhythm of breathing patterns, and the symmetry of chest expansion. Each of these parameters provides valuable information about a person's respiratory status. Therefore, it is important to assess all of the listed parameters to have a comprehensive understanding of the individual's respiratory function.

3. Which of the following measures is not recommended to prevent pressure ulcers?

Correct answer: A

Rationale: Massaging a reddened area can cause further tissue damage by increasing pressure on already compromised skin. The other options, such as using specialized mattresses, adhering to repositioning schedules, and maintaining good skin care, are all recommended strategies to prevent pressure ulcers by reducing pressure and friction on vulnerable areas of the skin.

4. What is required for effective hand washing?

Correct answer: A

Rationale: To effectively wash hands, soap or detergent is essential as they help emulsify fats and oils, allowing them to be rinsed away. Hot water alone cannot effectively destroy bacteria, and a disinfectant is not typically required for routine hand washing.

5. Which type of illness is characterized by severe symptoms of relatively short duration?

Correct answer: B

Rationale: The correct answer is B: Acute Illness. Acute illnesses are characterized by the sudden onset of severe symptoms that typically last for a short duration. These conditions usually resolve within a defined period, unlike chronic illnesses that persist over a longer time frame. Choices C and D, Pain and Syndrome, are not specific types of illnesses but rather symptoms or clinical manifestations that can occur in various health conditions.

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