a nurse is preparing to administer a blood transfusion to a client which of the following actions should the nurse take a nurse is preparing to administer a blood transfusion to a client which of the following actions should the nurse take
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Nursing Elites

ATI RN

ATI Exit Exam 180 Questions Quizlet

1. A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct answer is B: Start the transfusion with 0.9% sodium chloride. 0.9% sodium chloride is the only IV solution that is compatible with blood products and should be used to prime the tubing before a transfusion. Choice A is incorrect because vital signs should be monitored more frequently, typically every 15 minutes at the beginning of the transfusion. Choice C is incorrect as blood transfusions are usually administered over 2-4 hours, not 6 hours. Choice D is incorrect as the first 500 mL of blood should be infused slowly over 1-2 hours to monitor for any adverse reactions.

2. Which is most likely to initiate periodontal disease?

Correct answer: D

Rationale: Plaque biofilm is the primary initiator of periodontal disease, as it harbors bacteria that can lead to inflammation and destruction of the periodontal tissues.

3. According to the principles of standard precautions, when should gloves be worn by healthcare providers?

Correct answer: D

Rationale: Gloves should be worn when providing oral hygiene as it involves potential exposure to bodily fluids, aligning with the standard precautions to prevent the transmission of infections. Providing a back massage, feeding a client, and providing hair care do not typically involve direct exposure to bodily fluids, so wearing gloves is not necessary in these scenarios according to standard precautions.

4. Diet therapy for Rudy, who has acute renal failure is low-protein, low potassium and low sodium. The nutrition instructions should include:

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

5. A nurse is assessing a client who is receiving enteral nutrition via a nasogastric tube. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: A gastric residual of 150 mL may indicate delayed gastric emptying and should be reported to the provider.

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