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

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?

A. Prime IV tubing with 0.9% sodium chloride
B. Use a 24-gauge IV catheter
C. Obtain filterless IV tubing
D. Place blood in the warmer for 1 hr

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. What is the meaning of PRN?

A. When advice
B. Immediately
C. When necessary
D. Now

Correct answer: C

Rationale: The correct meaning of PRN is 'when necessary.' The abbreviation 'PRN' comes from the Latin term 'pro re nata,' which is commonly used in medical contexts to indicate that a medication should be taken as needed, not at scheduled intervals. Choice A ('When advice') is incorrect as PRN does not refer to seeking advice. Choice B ('Immediately') is incorrect as PRN does not imply urgency. Choice D ('Now') is incorrect as PRN does not mean 'immediate' but rather 'as needed.' Therefore, the correct answer is C, 'When necessary.'

3. Which natural body defense plays an active role in preventing infection?

A. Yawning
B. Body hair
C. Hiccupping
D. Rapid eye movements

Correct answer: B

Rationale: Body hair plays an active role in preventing infection by acting as a filter to block pathogens. It helps to prevent harmful substances from entering the body through the skin, providing a physical barrier against potential infections.

4. A client has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse?

A. ''I am allergic to morphine.''
B. ''I take antacids several times a day.''
C. ''I had a blood clot in my leg several years ago.''
D. ''It hurts to take a deep breath.''

Correct answer: B

Rationale: The correct answer is the statement 'I take antacids several times a day.' Antacids can alter the absorption of heparin, potentially affecting its effectiveness and increasing the risk of clot formation. This is a significant concern as it can impact the therapeutic outcome of heparin therapy. The other statements are not directly related to potential complications or interactions with heparin therapy.

5. A client who is at 38 weeks gestation, is in active labor, and has ruptured membranes is being cared for by a nurse. What action should the nurse take?

A. Insert an indwelling urinary catheter
B. Apply fetal heart rate monitor
C. Initiate fundal massage
D. Initiate an oxytocin IV infusion

Correct answer: B

Rationale: When caring for a client in active labor with ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This helps monitor the well-being of the fetus during labor and delivery, enabling timely interventions if any fetal distress is detected. Inserting an indwelling urinary catheter may be required in some cases, but it is not the priority in the given scenario. Fundal massage is typically done after delivery to help the uterus contract and prevent postpartum hemorrhage. Initiating an oxytocin IV infusion may be indicated to augment labor, but it is not the initial action needed in this situation.