diego is undergoing blood transfusion of the first unit the earliest signs of transfusion reactions are diego is undergoing blood transfusion of the first unit the earliest signs of transfusion reactions are
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Nursing Elites

ATI RN

ATI Proctored Nutrition Exam 2019

1. Diego is undergoing blood transfusion of the first unit. The earliest signs of transfusion reactions are:

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

2. Why has an ACE inhibitor been prescribed following an MI?

Correct answer: B

Rationale: Following a myocardial infarction (MI), ACE inhibitors are commonly prescribed due to their proven benefit in reducing mortality and improving outcomes post-MI. These medications help by decreasing the workload of the heart, preventing remodeling of the heart chambers, and improving survival rates. While ACE inhibitors may have effects on potassium levels, the primary reason for their prescription post-MI is their mortality-reducing properties.

3. A client who is nonambulatory notifies the nurse that their trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

Correct answer: D

Rationale: In this situation, the nurse's priority should be to confine the fire. By confining the fire, the nurse can prevent it from spreading further and causing more harm. Activating the emergency fire alarm (choice A) is important but should come after confining the fire. Extinguishing the fire (choice B) might not be safe for the nurse to do without proper equipment and training. Evacuating the client (choice C) can be considered once the fire is confined to ensure the client's safety.

4. A client is receiving radiation therapy to the head and neck. Which of the following interventions should the nurse include?

Correct answer: D

Rationale: The correct intervention for a client receiving radiation therapy to the head and neck is to avoid exposure to direct sunlight. Direct sunlight should be avoided to protect the skin from further irritation and damage caused by the radiation therapy. Instructing the client to use an alcohol-free mouthwash is important to prevent irritation and maintain oral hygiene, making choice A incorrect. Applying heat packs to the radiation site is contraindicated as heat can further aggravate the skin, making choice B incorrect. Providing a diet low in carbohydrates is not directly related to radiation therapy to the head and neck, so choice C is also incorrect.

5. A nurse administers naloxone (Narcan) to a post-op patient experiencing respiratory sedation. What undesirable effect would the nurse anticipate after giving this medication?

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.

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