a patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is star
Logo

Nursing Elites

ATI RN

ATI Perfusion Quizlet

1. A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to

Correct answer: D

Rationale: The patient's symptoms, back pain, and difficulty breathing after the transfusion indicate a possible acute hemolytic reaction, a severe transfusion reaction. The priority action in this situation is to discontinue the transfusion immediately to prevent further complications. Infusing normal saline helps maintain the patient's intravascular volume and prevent renal damage. Administering oxygen or obtaining a urine specimen is not the most urgent action and could delay essential treatment. Notifying the healthcare provider is important but should come after ensuring the patient's safety by stopping the blood transfusion.

2. Which patient requires the most rapid assessment and care by the emergency department nurse?

Correct answer: B

Rationale: The correct answer is B because a neutropenic patient with a fever is at high risk for developing sepsis. Sepsis can progress rapidly and lead to life-threatening complications. Immediate assessment, obtaining cultures, and initiating antibiotic therapy are essential in this situation. Choices A, C, and D do not present with the same level of urgency as a neutropenic patient with a fever. Abdominal pain in a hemochromatosis patient, oozing gums after a tooth extraction in a thrombocytopenic patient, and nausea and diarrhea in a patient with sickle cell anemia, while concerning, do not indicate the same immediate risk of sepsis as a neutropenic patient with a fever.

3. The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient?

Correct answer: C

Rationale: The correct answer is C: 'Do you take medication containing salicylates?' Petechiae are tiny, pinpoint, red or purple spots on the skin due to bleeding under the skin. Salicylates, which are found in medications like aspirin, interfere with platelet function and can lead to petechiae and ecchymoses. Asking about salicylate-containing medications is crucial in this situation. Choices A, B, and D are incorrect because they are not directly related to the development of petechiae.

4. Which instruction will the nurse plan to include in discharge teaching for a patient admitted with a sickle cell crisis?

Correct answer: C

Rationale: The correct answer is C: 'Avoid exposure to crowds when possible.' This instruction is crucial in discharge teaching for a patient admitted with a sickle cell crisis because exposure to crowds increases the risk of infection, which is the most common cause of sickle cell crisis. Choices A, B, and D are incorrect. Taking a daily multivitamin with iron (Choice A) may be beneficial for some individuals but is not specifically related to managing sickle cell crisis. Limiting fluids to 2 to 3 quarts per day (Choice B) is not typically recommended for patients with sickle cell crisis, as adequate hydration is important. Drinking only two caffeinated beverages daily (Choice D) is not a priority instruction in managing sickle cell crisis.

5. The nurse is educating a patient who was discharged from the hospital after having cardiac surgery one week ago. The nurse recognizes the patient understands medication management when he/she states:

Correct answer: A

Rationale: The correct answer is A. Lisinopril is commonly prescribed post-cardiac surgery to manage blood pressure and reduce the risk of heart failure. It is important for the patient to take Lisinopril daily as prescribed to achieve optimal outcomes. Choice B is incorrect as metoprolol is usually prescribed on a regular schedule to manage heart conditions, not just when symptoms occur. Choice C is incorrect because nitroglycerin should be kept in a cool, dry place, not in a pocket where it could be exposed to heat or moisture. Choice D is incorrect as pain medication should be taken as prescribed for adequate pain control, not just when pain is severe.

Similar Questions

The health care provider's progress note for a patient states that the complete blood count (CBC) shows a 'shift to the left.' Which assessment finding will the nurse expect?
The nurse is caring for a patient who is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching?
The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care?
Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia?
Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses