the nurse is assessing a client with a history of heart failure who is receiving a unit of packed red blood cells the clients respiratory rate is 33 b the nurse is assessing a client with a history of heart failure who is receiving a unit of packed red blood cells the clients respiratory rate is 33 b
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Nursing Elites

ATI RN

Endocrinology Exam

1. The nurse is assessing a client with a history of heart failure who is receiving a unit of packed red blood cells. The client’s respiratory rate is 33 breaths/min and blood pressure is 140/90 mm Hg. Which action does the nurse take first?

Correct answer: Slow the infusion rate of the transfusion

Rationale: In this scenario, the client is showing signs of a potential transfusion reaction, indicated by an increased respiratory rate. The nurse's initial action should be to slow down the infusion rate of the packed red blood cells to prevent further complications. Administering diphenhydramine or stopping the infusion should not be the first actions taken, as the priority is to ensure the client's safety and prevent adverse reactions. Continuing to monitor vital signs without taking immediate action to address the increased respiratory rate would delay appropriate intervention.

2. A client is taking Desmopressin for Diabetes Insipidus. For which of the following adverse effects should the nurse monitor?

Correct answer: D

Rationale: Headache is an adverse effect that the nurse should monitor for in a client taking Desmopressin for Diabetes Insipidus. It can be an early sign of water intoxication, which is a potential complication of desmopressin therapy due to excessive water retention in the body.

3. Why do older adult female clients need less iron than younger adult female clients?

Correct answer: C

Rationale: The correct answer is C. Older adult female clients need less iron than younger adult female clients because as women go through menopause, they no longer lose blood through menstruation, leading to a reduced need for iron. Choice A is incorrect because producing more red blood cells does not directly correlate with needing less iron. Choice B is incorrect as carrying oxygen more efficiently does not necessarily decrease the need for iron. Choice D is incorrect as exercising more does not explain the decreased need for iron in older adult female clients.

4. Canola oil produced from genetically modified canola plants altered to be herbicide-resistant is an example of a:

Correct answer: genetically modified food.

Rationale: The correct answer is 'genetically modified food.' Canola oil derived from genetically modified canola plants falls into this category because the plant's genome has been altered to exhibit herbicide resistance. This genetic modification makes it a genetically modified food. Choice A, 'pesticide-free food,' is incorrect as the genetic modification is to resist herbicides, not pesticides. Choice B, 'saturated fat food,' is incorrect as it does not accurately describe the genetic modification of the canola plants. Choice D, 'product that is pure,' is too vague and does not address the genetic modification aspect of the canola plants.

5. Lily weighed 8 pounds and was 21 inches long at birth. She was __________ than the average baby.

Correct answer: B

Rationale: Lily weighed 8 pounds and was 21 inches long at birth. Being both heavier and longer than average babies typically are at birth, Lily would be considered heavier and longer compared to the average baby. This makes choice B, 'heavier and longer,' the correct answer. Choices A, C, and D are incorrect because Lily was not shorter or lighter than the average baby at birth.

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