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. What is the priority action if a patient experiences hypoglycemia after an insulin dose?

A. Check the patient's blood glucose level
B. Administer IV dextrose
C. Document the incident
D. Continue monitoring the patient

Correct answer: A

Rationale: The priority action when a patient experiences hypoglycemia after an insulin dose is to check the patient's blood glucose level. This is crucial to confirm hypoglycemia before initiating any treatment. While administering IV dextrose may be necessary if the patient's blood glucose level is critically low, confirming hypoglycemia is essential to guide appropriate interventions. Documenting the incident is important for documentation purposes but is not the immediate priority when the patient's safety is at risk. Continuing to monitor the patient is essential, but it should follow the confirmation and initial management of hypoglycemia.

3. What is an escharotomy and why is it performed?

A. A surgical incision made to improve circulation in burn injuries
B. A procedure to remove dead tissue from a wound
C. A procedure to remove excess fluid from the lungs
D. A procedure to relieve pain from burns

Correct answer: A

Rationale: An escharotomy is a surgical procedure involving an incision through the eschar (dead tissue) to relieve pressure in burn injuries. It is performed to improve circulation to the affected area, prevent further damage, and restore blood flow. Choice B is incorrect because an escharotomy is not primarily focused on removing dead tissue but rather on relieving pressure. Choice C is incorrect as it describes a procedure related to pulmonary issues, not burn injuries. Choice D is incorrect because while pain relief may be a result of an escharotomy, it is not the primary purpose of the procedure.

4. A client is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?

A. Lie on your left side.
B. Lie on your right side.
C. Increase your fluid intake.
D. Decrease your fluid intake.

Correct answer: B

Rationale: After a liver biopsy, the nurse should instruct the client to lie on the right side. This position helps apply pressure to the biopsy site, promoting hemostasis and reducing the risk of bleeding. Lying on the left side may not provide adequate pressure to the site. Increasing fluid intake is generally beneficial to prevent dehydration and aid in the recovery process, whereas decreasing fluid intake could lead to dehydration and possible complications. Therefore, the correct instruction is to lie on the right side.

5. What should be monitored for in a patient with compartment syndrome?

A. Unrelieved pain, pallor, and pulselessness
B. Localized redness and swelling
C. Fever and infection
D. Muscle weakness and fatigue

Correct answer: A

Rationale: Correct Answer: A. Unrelieved pain, pallor, and pulselessness are classic signs of compartment syndrome that indicate inadequate blood flow to the affected area. These symptoms are crucial to monitor as they signify a medical emergency requiring immediate intervention. Choices B, C, and D are incorrect because they do not align with the typical manifestations of compartment syndrome. Localized redness and swelling may be present but are not the primary indicators. Fever and infection are also not specific to compartment syndrome, and muscle weakness and fatigue are not typically prominent symptoms of this condition.