what is the appropriate action for a nurse when administering a blood transfusion
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2020

1. What is the appropriate action for a healthcare professional when administering a blood transfusion?

Correct answer: A

Rationale: The appropriate action for a healthcare professional when administering a blood transfusion is to verify the patient's identity. This step is essential to ensure that the correct blood product is given to the right patient, preventing any errors or adverse reactions. While monitoring vital signs and staying with the patient during the initial phase of the transfusion are also important steps, the primary action of verifying the patient's identity takes precedence to uphold patient safety and prevent any potential harm.

2. A client who is at 36 weeks of gestation is being taught about nonstress testing. Which of the following statements should the nurse include in the teaching?

Correct answer: C

Rationale: The correct answer is C. In a nonstress test, the client is required to press a handheld button whenever fetal movement is felt, which is then recorded on the monitor. This action helps assess the baby's heart rate in response to its movements, providing valuable information about the baby's well-being. Choices A, B, and D are incorrect because the nonstress test does not involve determining the length of the cervix, monitoring blood pressure, or being completed in 5 minutes. These aspects are not part of the nonstress testing procedure and are unrelated to the purpose of the test.

3. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take when caring for a client with a prescription for wound irrigation is to cleanse the wound from the center outwards. This technique helps prevent contamination by pushing debris away from the wound rather than into it. Choice A is incorrect because wearing sterile gloves is important during wound care but not specifically mentioned for wound irrigation. Choice B is incorrect because warming the irrigation solution to a specific temperature is not a standard recommendation and can potentially harm the client. Choice D is incorrect because the size of the syringe may vary based on the wound size and depth, so using a 20 mL syringe is not a universal guideline.

4. A nurse is teaching a client who has peptic ulcer disease about preventing exacerbations. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is B: Limit alcohol consumption. Alcohol consumption can aggravate peptic ulcer disease by increasing gastric acid secretion, potentially leading to exacerbations. Choices A, C, and D are incorrect. Choice A is not recommended because antacids containing magnesium can interfere with other medications or conditions the client may have. Choice C is a good recommendation; however, it is not the priority instruction for preventing exacerbations. Choice D is also incorrect as caffeine can stimulate gastric acid secretion, which can worsen peptic ulcer disease.

5. When managing a physically assaultive client, the nurse's INITIAL priority is to

Correct answer: C

Rationale: When dealing with a physically assaultive client, the initial priority is to focus on restoring the client's self-control and preventing further escalation. Restricting the client to the room (choice A) may escalate the situation and is not the initial priority. Placing the client under one-to-one supervision (choice B) is important but comes after ensuring the client's self-control. Clearing the immediate area of other clients (choice D) is essential for safety but is not the initial priority when compared to restoring the client's self-control.

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