which intervention should the nurse implement for a patient receiving a blood transfusion
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Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. What intervention should the nurse implement for a patient receiving a blood transfusion?

Correct answer: B

Rationale: The correct intervention for a patient receiving a blood transfusion is to monitor the patient for signs of circulatory overload. This is crucial to prevent fluid overload, which can lead to serious complications. Administering antihistamines is not a routine intervention during blood transfusions unless the patient shows signs of an allergic reaction. Ensuring the completion of the blood transfusion within a specific time frame is not as critical as monitoring for circulatory overload. Checking vital signs every 30 minutes is essential, but the specific focus should be on monitoring for signs of circulatory overload.

2. A healthcare professional is assessing a patient with pneumonia. Which finding is most concerning?

Correct answer: D

Rationale: Crackles heard in the lung bases are most concerning in a patient with pneumonia as they suggest fluid accumulation in the lungs, indicating possible severe infection or respiratory distress. Prompt intervention is required to prevent further complications.\n\nChoice A, fever of 101°F, is common in infections like pneumonia but may not be as immediately concerning as crackles indicating fluid in the lungs.\n\nChoice B, a blood pressure of 140/90 mmHg, is within normal limits and not directly indicative of pneumonia severity.\n\nChoice C, a heart rate of 95 beats per minute, is slightly elevated but not as critical as crackles suggesting fluid in the lungs.

3. A case manager at an assisted living facility is reviewing the use of complementary health practices by several clients. Which of the following actions should the case manager plan to take?

Correct answer: B

Rationale: The correct answer is B. Tai chi is a recognized complementary health practice for stress reduction. Scheduling time for a new client to continue tai chi practice aligns with supporting holistic care. Choice A is incorrect because reporting a client's use of echinacea as a contraindication to aspirin therapy is not necessary without further context or evidence of interactions. Choice C is wrong because yoga can indeed be effective in reducing manifestations of menopause. Choice D is also incorrect because while cranberry juice is known to help prevent urinary tract infections, it is not typically used to treat existing infections.

4. A nurse manager notices a discrepancy in a nurse's narcotics record. What is the appropriate action?

Correct answer: B

Rationale: The appropriate action when a nurse manager notices a discrepancy in a nurse's narcotics record is to report the discrepancy to the pharmacy. Reporting such discrepancies is crucial to ensure accountability and patient safety. Choice A is incorrect because the nurse manager should not confront the nurse directly without proper investigation. Choice C is incorrect because reporting to the nurse manager may not address the issue effectively. Choice D is incorrect because ignoring the discrepancy can compromise patient safety and violates protocols.

5. A client with hyperthyroidism is prescribed propranolol. Which finding indicates that the propranolol is effective?

Correct answer: B

Rationale: The correct answer is B because a decrease in blood pressure is an expected outcome when propranolol, a beta-blocker, is effectively managing hyperthyroidism. Propranolol helps control symptoms such as tachycardia and hypertension associated with hyperthyroidism. Choices A, C, and D are incorrect because weight gain, increased energy, and an increased respiratory rate are not direct indicators of propranolol's effectiveness in treating hyperthyroidism.

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