what is the most important step when preparing to administer a blood transfusion

ATI LPN

ATI Comprehensive Predictor PN

1. What is the most important step when preparing to administer a blood transfusion?

A. Check if the client has a fever
B. Ensure the blood type is compatible with the client
C. Administer the blood via IV push
D. Ensure the blood is warmed to body temperature

Correct answer: B

Rationale: The correct answer is B: Ensure the blood type is compatible with the client. This is the most crucial step in preparing for a blood transfusion to prevent severe transfusion reactions. Checking the client for a fever (Choice A) is important but not the most critical step. Administering blood via IV push (Choice C) is incorrect as blood transfusions are usually administered as a slow drip. Warming the blood to body temperature (Choice D) is not a standard practice and can lead to hemolysis, making it an incorrect choice.

2. What are the early signs of DVT?

A. Leg pain, swelling, and redness
B. Shortness of breath and high fever
C. Cough and chest pain
D. Decreased oxygen saturation and low blood pressure

Correct answer: A

Rationale: The correct answer is A: Leg pain, swelling, and redness are early signs of DVT. DVT (Deep Vein Thrombosis) is a condition where blood clots form in deep veins, commonly in the legs. These clots can cause symptoms like pain, swelling, and redness in the affected leg. Choices B, C, and D describe symptoms more commonly associated with other conditions like pulmonary embolism (shortness of breath and high fever), respiratory issues (cough and chest pain), and cardiovascular problems (decreased oxygen saturation and low blood pressure), respectively. Therefore, they are not indicative of early signs of DVT.

3. A client who is to undergo a colonoscopy is being taught by a nurse about the procedure. Which of the following statements by the client indicates an understanding of the teaching?

A. I will drink liquids right up until the procedure.
B. I will need to stop eating and drinking at least 24 hours before the procedure.
C. I will be sedated and will not feel any pain during the procedure.
D. I will not need to follow any specific dietary restrictions for this procedure.

Correct answer: C

Rationale: Choice C is the correct answer. During a colonoscopy, clients are typically sedated, so they do not feel any pain during the procedure. Choices A, B, and D are incorrect. Clients are usually required to stop eating and drinking at least 24 hours before a colonoscopy, and there are specific dietary restrictions that need to be followed before the procedure to ensure a successful examination.

4. What is the priority intervention for sepsis?

A. Administer IV antibiotics
B. Monitor blood pressure
C. Administer fluids
D. All of the above

Correct answer: D

Rationale: In the management of sepsis, prompt intervention is crucial. Administering IV antibiotics is essential to target the underlying infection. Monitoring blood pressure helps assess the patient's hemodynamic status. Administering fluids is vital to maintain adequate perfusion. Therefore, all the options are integral components of the initial management of sepsis, making 'All of the above' the correct answer. Choosing any single intervention over the others may delay optimal care and compromise patient outcomes.

5. A nurse is teaching a client who is to undergo total knee arthroplasty about postoperative care. Which of the following instructions should the nurse include?

A. Apply heat to the affected knee
B. Avoid placing pillows under the knee
C. Avoid moving the knee for 2-3 days
D. Apply ice to the affected knee for 24-48 hours

Correct answer: D

Rationale: The correct answer is to apply ice to the affected knee for 24-48 hours. Applying ice helps to reduce inflammation and pain after knee surgery, promoting healing. Choice A is incorrect because heat is not recommended postoperatively, as it can increase swelling. Choice B is incorrect because pillows should be placed under the knee to keep it elevated. Choice C is incorrect because early mobilization is essential for preventing complications such as blood clots.