ATI RN
ATI Perfusion Quizlet
1. A patient with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the healthcare provider before obtaining and administering platelets?
- A. Platelet count is 42,000/µL
- B. Petechiae are present on the chest
- C. Blood pressure (BP) is 94/56 mm Hg
- D. Blood is oozing from the venipuncture site
Correct answer: A
Rationale: The correct answer is A. Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/µL unless the patient is actively bleeding. In this case, with a platelet count of 42,000/µL, the count is not critically low, and the patient is not actively bleeding. Therefore, the nurse should consult with the healthcare provider before giving the transfusion. Choices B, C, and D are incorrect because the presence of petechiae, low blood pressure, and oozing from the venipuncture site are common findings in patients with ITP and do not necessarily require immediate consultation before administering a platelet transfusion.
2. What is the MOST COMMON cause of vaginal bleeding immediately after birth?
- A. Uterine atony
- B. Genital lacerations
- C. Abnormal clotting mechanisms
- D. Endometritis
Correct answer: A
Rationale: Vaginal bleeding immediately after birth is most commonly due to uterine atony. Uterine atony is the failure of the uterine muscle to contract adequately after childbirth, leading to postpartum hemorrhage. This condition is more frequent than genital lacerations, abnormal clotting mechanisms, or endometritis as a cause of immediate postpartum bleeding.
3. A nurse administers naloxone (Narcan) to a post-op patient experiencing respiratory sedation. What undesirable effect would the nurse anticipate after giving this medication?
- A. Drowsiness
- B. Tics and tremors
- C. Increased Pain
- D. Nausea and vomiting
Correct answer: C
Rationale: Naloxone reverses the effects of narcotics. Although the patient�s respiratory status will improve after administration of naloxone, the pain will be more acute.
4. Mina, who is suspected of an ovarian tumor is scheduled for a pelvic ultrasound. The nurse provides which preprocedure instruction to the client?
- A. Eat a light breakfast only
- B. Maintain an NPO status before the procedure
- C. Wear comfortable clothing and shoes for the procedure
- D. Drink six to eight glasses of water without voiding before the test
Correct answer: D
Rationale: A pelvic ultrasound requires the client to have a full bladder because the bladder acts as a window through which pelvic organs, such as the uterus and ovaries, can be visualized more clearly. The full bladder pushes the intestines out of the way and provides a better acoustic pathway for the ultrasound waves. Without this, the pelvic organs might be obscured, and the images would be less accurate.
5. What findings would the nurse consider normal in assessing the anterior fontanel of a neonate?
- A. Closed anterior fontanel
- B. Sunken anterior fontanel
- C. Bulging anterior fontanel
- D. Pulsating anterior fontanel
Correct answer: D
Rationale: The correct answer is D: Pulsating anterior fontanel. The fontanel should feel flat, firm, and well demarcated. Pulsations are frequently visible at the anterior fontanel, which is a normal finding in a neonate. A closed anterior fontanel, as mentioned, is a potential sign of a major abnormality. A sunken or bulging fontanel (when the infant is quiet) may be indicative of distress or a major abnormality. Therefore, options A, B, and C are considered abnormal findings when assessing the anterior fontanel of a neonate.
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