a nurse is preparing to administer a blood transfusion what is the first step a nurse is preparing to administer a blood transfusion what is the first step
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2024

1. A healthcare professional is preparing to administer a blood transfusion. What is the first step?

Correct answer: B

Rationale: The correct first step before administering a blood transfusion is to verify that the client's blood type matches the blood product. This step is crucial to prevent transfusion reactions due to incompatibility. Choice A is incorrect because blood should not be administered through an IV push for a blood transfusion. Choice C is incorrect because it is not necessary for the client to eat before a blood transfusion. Choice D is incorrect because administering a diuretic is not a standard practice before starting a blood transfusion.

2. What is the correct way to assess for pitting edema?

Correct answer: A

Rationale: The correct way to assess for pitting edema is to press over a bony area, typically the tibia, for 5 seconds and then release. This allows for the identification of pitting edema, characterized by an indentation that persists for a few seconds. Choice B is incorrect as pitting edema assessment does not involve checking for discoloration. Choice C is incorrect as the presence of a rash is not indicative of pitting edema. Choice D is incorrect as rebound tenderness is a different assessment used for abdominal conditions, not for pitting edema.

3. A nurse is providing discharge instructions to a client after a myocardial infarction. Which of the following should be included?

Correct answer: B

Rationale: The correct answer is B: 'Monitor for chest pain and report any recurrence.' After a myocardial infarction, it is crucial for clients to be vigilant about any signs of chest pain as it could indicate a recurrent event. Prompt reporting of chest pain can lead to timely intervention, preventing further complications. Choice A is incorrect because resuming normal activities immediately after a heart attack can be dangerous and is not recommended. Choice C is also incorrect as avoiding all physical activity for 6 months is excessive and can lead to deconditioning. Choice D is incorrect as medications prescribed after a myocardial infarction are usually meant to be taken regularly as prescribed, not just as needed.

4. A nurse is caring for a client who has hypertension and is receiving enalapril. Which of the following findings should the nurse report to the provider?

Correct answer: B

Rationale: The correct answer is B: Persistent cough. Enalapril is an ACE inhibitor that can cause a persistent cough as a common side effect. This symptom should be reported to the healthcare provider to evaluate if a medication adjustment is needed. Choices A, C, and D are not typically associated with enalapril use and are less likely to be directly related to the medication. Increased heart rate, constipation, and sweating are not commonly linked to enalapril, so they are not the priority findings to report in this case.

5. A patient with social anxiety disorder is starting cognitive-behavioral therapy (CBT). Which statement by the nurse best explains the purpose of this therapy?

Correct answer: A

Rationale: Cognitive-behavioral therapy (CBT) is a structured, short-term psychotherapy that aims to help patients identify and change negative thought patterns and behaviors associated with anxiety. By understanding and altering these patterns, individuals can learn to manage and alleviate their symptoms effectively. Choice A is the correct answer as it accurately describes the purpose of CBT for social anxiety disorder. Choices B, C, and D are incorrect. B is incorrect because while childhood experiences may be explored, the primary focus of CBT is on thought patterns and behaviors in the present. C is incorrect because although relaxation techniques may be a component of CBT, the primary goal is not just to teach relaxation but to address underlying cognitive and behavioral patterns. D is incorrect because the goal of CBT is not avoidance but rather to confront and manage anxiety-provoking situations.

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