a nurse is to administer a unit of whole blood to a postoperative client what does the nurse do to ensure the safety of the blood transfusion
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Nursing Elites

ATI RN

Endocrinology Exam

1. A nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion?

Correct answer: C

Rationale: Ensuring the safety of a blood transfusion is crucial to prevent potential errors or adverse reactions. Checking the blood identification numbers with the laboratory technician at the Blood Bank when the blood is dispersed helps confirm that the correct blood product is being administered to the right patient, reducing the risk of transfusion reactions. The other choices are incorrect because asking the client to say and spell their full name (Choice A) is a part of the identification process but not specific to ensuring the safety of the blood transfusion. While having another qualified healthcare professional check the unit (Choice B) is a good practice, the direct verification with the Blood Bank technician is a more critical step in ensuring the correct blood product is administered. Choice D is irrelevant to ensuring the safety of the blood transfusion as it addresses infection control measures.

2. A client who has a head injury is transported to the emergency department. Which assessment does the emergency department nurse perform immediately?

Correct answer: C

Rationale: In a client with a head injury, assessing the respiratory status is the priority as airway and breathing are essential for life. Immediate attention to respiratory status is crucial to ensure adequate oxygenation. While assessing pupil response and motor function are also important in head injuries, ensuring the client's ability to breathe takes precedence. Short-term memory assessment is not a priority in the emergent phase of care for a client with a head injury.

3. A client is receiving an IV infusion of an antibiotic. The client calls the nurse feeling uneasy due to congestion. Which action by the nurse is most appropriate?

Correct answer: B

Rationale: In this situation, the client's symptoms of congestion and feeling uneasy may indicate an anaphylactic reaction, which can be life-threatening. The most appropriate action is to call the Rapid Response Team to provide immediate assistance and interventions. Elevating the head of the bed, administering diphenhydramine, or slowing the IV infusion rate are not the priority actions in the case of a potential severe allergic reaction. These interventions may delay necessary emergency care and potentially worsen the client's condition.

4. The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse's priority?

Correct answer: C

Rationale: The correct answer is to assess the pulse and blood pressure. Distended neck veins can indicate fluid volume overload or heart failure, which can lead to hemodynamic instability. Assessing the pulse and blood pressure will provide immediate information on the client's cardiovascular status. Documenting the observation in the chart (choice A) is important but not the priority when immediate assessment is needed. Measuring urine specific gravity and volume (choice B) is important for assessing renal function but is not the priority in this situation. Assessing the client's deep tendon reflexes (choice D) is not relevant to addressing distended neck veins in a client sitting to eat.

5. When obtaining a client’s vital signs, the nurse assesses a blood pressure of 134/88 mm Hg. What is the nurse’s best intervention?

Correct answer: D

Rationale: The correct answer is to teach the client lifestyle modifications to decrease blood pressure. A blood pressure reading of 134/88 mm Hg falls within the prehypertension range. The initial approach to managing prehypertension involves lifestyle modifications such as dietary changes, exercise, and stress reduction techniques. Calling the healthcare provider without attempting non-pharmacological interventions first is premature. Reassessing blood pressure at the next follow-up appointment may delay necessary interventions. Administering additional antihypertensive medication is not indicated at this stage as lifestyle modifications are the first line of treatment for prehypertension.

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