ATI RN
ATI RN Custom Exams Set 4
1. The client diagnosed with thalassemia, a hereditary anemia, is to receive a transfusion of packed RBCs. The cross-match reveals the presence of antibodies that cannot be cross-matched. Which precaution should the nurse implement when initiating the transfusion?
- A. Start the transfusion at 10-15 mL per hour for 15-30 minutes
- B. Re-crossmatch the blood until the antibodies are identified
- C. Have the client sign a permit to receive uncrossmatched blood
- D. Have the unlicensed nursing assistant stay with the client
Correct answer: A
Rationale: Starting the transfusion slowly at 10-15 mL per hour for 15-30 minutes is essential when the cross-match reveals the presence of antibodies that cannot be cross-matched. This precaution allows the nurse to monitor for any adverse reactions due to the antibodies. Re-crossmatching the blood until the antibodies are identified (choice B) may delay the transfusion process and put the client at risk. Having the client sign a permit to receive uncrossmatched blood (choice C) is not a standard practice and does not address the immediate need for precautions during transfusion. Having the unlicensed nursing assistant stay with the client (choice D) is unrelated to the safe initiation of the transfusion and is not a precaution specific to managing antibodies in blood products.
2. Generally, lifestyle-related diseases share common risk factors. Which of the following is NOT one of them?
- A. Physical activity
- B. Smoking
- C. Genetics
- D. Nutrition
Correct answer: C: Genetics
Rationale: Common risk factors for lifestyle-related diseases typically include aspects of one's lifestyle that can be modified or controlled, such as physical activity, smoking habits, and nutrition. These factors can be changed to prevent or manage lifestyle-related diseases. Genetics, on the other hand, is not a modifiable risk factor, meaning it cannot be changed or controlled. Therefore, it is not considered a common risk factor for lifestyle-related diseases. Understanding the modifiable risk factors for these diseases allows for better prevention and management strategies, and helps reduce the risk of complications.
3. A nurse is caring for a client who has a history of angina. The client reports chest pain. Which of the following actions should the nurse take?
- A. Administer sublingual nitroglycerin every 5 minutes
- B. Administer aspirin 325 mg
- C. Encourage the client to use deep breathing exercises
- D. Apply oxygen at 2 L/min via nasal cannula
Correct answer: A
Rationale: The correct action for the nurse to take when a client with a history of angina reports chest pain is to administer sublingual nitroglycerin every 5 minutes. Nitroglycerin helps dilate blood vessels, improving blood flow to the heart and relieving chest pain associated with angina. Aspirin is often given during a suspected heart attack, not for immediate relief of angina. Deep breathing exercises may be beneficial for anxiety or respiratory conditions but are not the first-line intervention for angina. Oxygen therapy is not the initial treatment for angina unless the client is hypoxic.
4. Nurse Managers work with staff to educate them about ways to diffuse potentially violent situations. Which of the following diagnoses can staff expect to be more frequently associated with violence?
- A. Alcohol or drug withdrawal
- B. Anxiety
- C. Depression
- D. Confusion
Correct answer: A
Rationale: Alcohol or drug withdrawal is more frequently associated with violence as these conditions alter a person's inhibitions. Gilmore (2006) highlights that working with the public involves inherent risks and stressors. Individuals with head trauma, mental illnesses, and those withdrawing from substances are more likely to respond with violence. Anxiety, depression, and confusion do not typically lead to increased violent behavior compared to conditions involving substance withdrawal.
5. Determining nursing care priorities is a part of which of the following steps for determining and fulfilling the nursing care needs of the patient?
- A. Evaluation
- B. Planning
- C. Implementation
- D. Assessment
Correct answer: B
Rationale: Corrected Rationale: Planning in nursing involves setting priorities based on the identified patient needs, establishing goals, and developing a plan of care. Evaluation involves assessing the effectiveness of the care provided, implementation is the phase where the care plan is carried out, and assessment is the initial step of collecting data to identify the patient's needs. Therefore, in the context of determining nursing care priorities, the correct step is Planning (choice B).