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. A client is learning to use a cane. What instruction is essential for this client?

A. Advance the cane and the weaker leg at the same time
B. Maintain two points of support on the ground at all times
C. Use the cane on the weaker side for better support
D. Advance the cane 30 to 45 cm with each step

Correct answer: B

Rationale: The correct instruction for a client learning to use a cane is to maintain two points of support on the ground at all times. This ensures better stability and reduces the risk of falls. Choice A is incorrect because advancing the cane and the weaker leg simultaneously may lead to imbalance. Choice C is incorrect because the cane should be used on the stronger side to provide support. Choice D is incorrect because there is no specific measurement for advancing the cane with each step, and the focus should be on maintaining stability.

3. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take to promote wound healing?

A. Apply heat to the surgical site
B. Ensure the client consumes adequate protein
C. Encourage the client to ambulate frequently
D. Instruct the client to drink 4 liters of water daily

Correct answer: B

Rationale: The correct answer is to ensure the client consumes adequate protein. Protein is essential for wound healing as it supports tissue repair. Applying heat to the surgical site (choice A) is not recommended as it can increase inflammation. Although ambulation (choice C) is beneficial for circulation and preventing complications, it is not directly related to promoting wound healing. Instructing the client to drink 4 liters of water daily (choice D) is excessive and not specifically related to wound healing in this context.

4. Which intervention is most important for a client with rheumatoid arthritis?

A. Massage inflamed joints with creams and oils
B. Provide support to flexed joints with pillows and pads
C. Position the client on their abdomen several times a day
D. Assist with heat application and range of motion exercises

Correct answer: D

Rationale: The most important intervention for a client with rheumatoid arthritis is to assist with heat application and range of motion exercises. Heat application helps reduce stiffness and improve joint flexibility, while range of motion exercises help maintain mobility and prevent contractures. Massaging inflamed joints with creams and oils may provide temporary relief but does not address the root cause of stiffness and limited mobility in rheumatoid arthritis. Providing support to flexed joints with pillows and pads can be helpful for comfort but does not actively promote mobility. Positioning the client on their abdomen several times a day is not a standard intervention for managing rheumatoid arthritis.

5. What is the main symptom of left-sided heart failure?

A. Shortness of breath
B. Edema
C. Increased heart rate
D. Decreased urine output

Correct answer: A

Rationale: Shortness of breath is the main symptom of left-sided heart failure because it results from pulmonary congestion due to fluid buildup in the lungs. Edema, increased heart rate, and decreased urine output are associated with right-sided heart failure rather than left-sided heart failure.