a nurse is caring for a client who is receiving a blood transfusion and reports chills which of the following actions should the nurse take first

ATI RN

ATI Exit Exam RN

1. While caring for a client receiving a blood transfusion who reports chills, which action should the nurse take first?

A. Stop the transfusion.
B. Administer acetaminophen as prescribed.
C. Notify the provider.
D. Check the client's blood pressure.

Correct answer: A

Rationale: The correct action for the nurse to take first when a client reports chills during a blood transfusion is to stop the transfusion. Chills can indicate a transfusion reaction, which is a potentially serious situation. Stopping the transfusion immediately is crucial to prevent further complications. Administering acetaminophen or checking the client's blood pressure can come after ensuring the safety of the client by stopping the transfusion. Notifying the provider is important, but the immediate priority is to stop the transfusion.

2. A nurse is preparing to administer an immunization to a 6-month-old infant. Which of the following actions should the nurse take to reduce pain at the injection site?

A. Administer the immunization in the deltoid muscle
B. Apply a cold compress to the injection site
C. Apply pressure to the injection site for 5 minutes
D. Administer a local anesthetic at the injection site

Correct answer: D

Rationale: Administering a local anesthetic at the injection site can help reduce pain during immunizations in infants. Options A, B, and C are incorrect. Administering the immunization in the deltoid muscle may not provide pain relief. Applying a cold compress or pressure to the injection site is not as effective as using a local anesthetic to reduce pain.

3. Which lab value should be monitored in patients receiving furosemide?

A. Monitor potassium levels
B. Monitor sodium levels
C. Monitor calcium levels
D. Monitor glucose levels

Correct answer: A

Rationale: The correct answer is to monitor potassium levels in patients receiving furosemide. Furosemide is a loop diuretic that can lead to potassium loss in the urine, potentially causing hypokalemia. Monitoring potassium levels is crucial to prevent complications associated with low potassium levels, such as cardiac arrhythmias. Monitoring sodium levels (choice B) is not typically necessary with furosemide use, as it primarily affects potassium levels. Calcium levels (choice C) and glucose levels (choice D) are not directly impacted by furosemide and require monitoring for other conditions or medications.

4. What is the initial intervention for a patient with chest pain?

A. Administer aspirin
B. Administer nitroglycerin
C. Provide pain relief
D. Prepare for surgery

Correct answer: A

Rationale: The correct initial intervention for a patient with chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation by inhibiting platelet aggregation, which can be beneficial in case the chest pain is due to a cardiac event. Administering nitroglycerin may follow aspirin administration to help relieve chest pain by dilating blood vessels. Providing pain relief is a general approach and may not address the underlying cause of chest pain. Preparing for surgery would not be the initial intervention for chest pain unless there are specific indications for immediate surgical intervention.

5. What is the priority intervention for a patient with fluid overload?

A. Administer diuretics
B. Administer IV fluids
C. Provide oral fluids
D. Provide chest physiotherapy

Correct answer: A

Rationale: The correct answer is to administer diuretics. Diuretics help reduce excess fluid in cases of fluid overload, making it the priority intervention. Administering additional IV fluids (choice B) would exacerbate the problem by adding more fluid. Providing oral fluids (choice C) is not the priority as the excess fluid needs to be removed first. Chest physiotherapy (choice D) is not the primary intervention for fluid overload.