a nurse is administering a blood transfusion to a client and suspects that the client is having an adverse reaction to the blood which of the followin

ATI RN

ATI Capstone Adult Medical Surgical Assessment 1

1. While administering a blood transfusion, a nurse suspects that the client is having an adverse reaction. Which of the following actions should the nurse take first?

A. Maintain IV access
B. Obtain the client's vital signs
C. Contact the provider
D. Stop the transfusion

Correct answer: D

Rationale: The correct first action for the nurse to take when suspecting an adverse reaction to a blood transfusion is to stop the transfusion immediately. Stopping the transfusion helps prevent further harm to the client. Maintaining IV access and obtaining vital signs are important steps but come after stopping the transfusion in this situation. Contacting the provider can be done after ensuring the client's safety by stopping the transfusion.

2. A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as the best choice for the client to include in their diet?

A. 1 packet of reconstituted dry onion soup
B. 3 oz of lean cured ham
C. 3 oz of chicken breast
D. ½ cup of canned baked beans

Correct answer: C

Rationale: For a client with hypertension, a low sodium diet is recommended to help control blood pressure. Among the food choices provided, the best option is 3 oz of chicken breast. Chicken breast is lean protein with lower sodium content compared to other choices. It is a healthier option for managing hypertension. Reconstituted dry onion soup (Choice A) and canned baked beans (Choice D) typically contain higher amounts of sodium, which can be detrimental for blood pressure management. Lean cured ham (Choice B) also tends to have a higher sodium content, making it less suitable for a client with hypertension.

3. What precaution should be advised to a patient following a cataract surgery?

A. Wear dark glasses while outdoors
B. Avoid NSAIDs
C. Use warm compresses
D. Apply cold packs

Correct answer: A

Rationale: Following cataract surgery, patients are advised to wear dark glasses while outdoors. This is crucial to protect the eyes from bright light and prevent complications such as excessive glare or discomfort. Choice B, avoiding NSAIDs, is not directly related to post-cataract surgery care. Choices C and D, using warm compresses and applying cold packs, are not typically part of the standard post-operative care for cataract surgery.

4. What is the priority intervention for a patient with possible acute coronary syndrome?

A. Administer nitroglycerin
B. Get IV access
C. Auscultate heart sounds
D. Administer aspirin

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with possible acute coronary syndrome as it helps dilate blood vessels, reduce chest pain, and improve blood flow to the heart. This intervention is crucial in managing acute coronary syndrome and should be given promptly. Getting IV access may be necessary, but administering nitroglycerin takes precedence to alleviate symptoms and prevent further heart damage. Auscultating heart sounds and administering aspirin are important aspects of the assessment and treatment plan, but they are not the priority interventions in the acute phase of suspected acute coronary syndrome.

5. What are the expected signs in a patient with compartment syndrome?

A. Unrelieved pain, pallor, and pulselessness
B. Fever and infection
C. Localized redness and swelling
D. Loss of sensation in the affected area

Correct answer: A

Rationale: In a patient with compartment syndrome, the classic signs include unrelieved pain, pallor, and pulselessness. These signs indicate compromised circulation and neurovascular function in the affected compartment. Fever and infection (Choice B) are not typical signs of compartment syndrome. Localized redness and swelling (Choice C) can be seen in other conditions like cellulitis but are not specific to compartment syndrome. Loss of sensation in the affected area (Choice D) may occur in some cases but is not as specific or consistent as unrelieved pain, pallor, and pulselessness in diagnosing compartment syndrome.