which of the following is a sign or symptom of a hemolytic reaction to blood transfusion
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Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam 2024

1. Which of the following is a sign or symptom of a hemolytic reaction to a blood transfusion?

Correct answer: A

Rationale: Hemoglobinuria is a characteristic sign of a hemolytic reaction to a blood transfusion. Hemolytic reactions can lead to the destruction of red blood cells, causing the release of hemoglobin into the urine, which presents as hemoglobinuria. Chest pain, urticaria, and distended neck veins are not specific signs of a hemolytic reaction and may be associated with other conditions or reactions.

2. When caring for a client who speaks a language different from their own, what action should the nurse take?

Correct answer: D

Rationale: When caring for a client who speaks a different language, it is essential for the nurse to review the facility policy about the use of an interpreter. Using a professional interpreter ensures accurate communication and protects the client's confidentiality. Requesting an interpreter of a specific sex or relying on family members or friends can lead to miscommunication or breaches of confidentiality. Directing attention towards the interpreter helps facilitate communication but does not address the need for a professional interpreter as per facility policy.

3. While teaching a newly hired nurse about varicella, a nurse in a pediatric clinic should include which of the following information?

Correct answer: A

Rationale: Children with varicella (chickenpox) are contagious until all vesicles are crusted over. The contagious period starts 1-2 days before the rash appears and continues until all lesions are dried and crusted. It is important to educate healthcare providers about the contagious period to prevent the spread of the virus to susceptible individuals.

4. A client experiencing dyspnea will receive continuous oxygen. Which oxygen device should be used to deliver a precise amount of oxygen?

Correct answer: B

Rationale: A Venturi mask is the most appropriate choice for delivering a precise amount of oxygen to a client with dyspnea. Unlike other oxygen delivery devices, the Venturi mask allows for accurate oxygen concentration delivery by controlling the amount of air entrained. This feature is crucial in ensuring the client receives the prescribed oxygen concentration, especially in cases where precise oxygen delivery is required.

5. When is additional Vitamin C not required?

Correct answer: B

Rationale: Vitamin C requirements are increased during infancy, childhood, and pregnancy due to growth and development. However, during young adulthood, the body generally requires a consistent amount of Vitamin C as it is not undergoing rapid growth or physiological changes that necessitate an increase in Vitamin C intake.

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