a nurse is caring for a client who is to receive a transfusion of packed rbcs which of the following actions should the nurse take

ATI RN

ATI Fundamentals Proctored Exam

1. A client is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?

A. Prime IV tubing with 0.9% sodium chloride
B. Use a 24-gauge IV catheter
C. Obtain filterless IV tubing
D. Place blood in the warmer for 1 hr

Correct answer: A

Rationale: Prior to administering a blood transfusion, it is essential to prime the IV tubing with 0.9% sodium chloride to prevent hemolysis of the blood cells. Using a smaller gauge IV catheter (e.g., 20 or 22 gauge) is recommended for blood transfusions to prevent hemolysis. Filterless IV tubing is contraindicated for blood transfusions as it does not have a filter to trap potential blood clots or debris. Warming blood is unnecessary and could lead to the development of bacteria in the blood product. Therefore, the correct action for the nurse to take is to prime the IV tubing with 0.9% sodium chloride.

2. A nurse is orienting a newly licensed nurse on performing a routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?

A. Apply a vest restraint if self-extubation is attempted.
B. Monitor ventilator settings every 8 hours.
C. Document tube placement in centimeters at the angle of the jaw.
D. Assess breath sounds every 1 to 2 hours.

Correct answer: D

Rationale: Assessing breath sounds every 1 to 2 hours is crucial in monitoring the client's respiratory status and identifying any potential complications promptly. Monitoring ventilator settings every 8 hours is important for overall ventilation management. Documenting the endotracheal tube placement accurately is essential to ensure proper positioning. Using a vest restraint if self-extubation is attempted is not a recommended intervention as it can lead to complications and should be avoided.

3. The healthcare provider orders the administration of an ampicillin capsule TID p.o. The healthcare provider should give the medication...

A. Three times a day orally
B. Three times a day after meals
C. Two times a day by mouth
D. Two times a day before meals

Correct answer: A

Rationale: In medical abbreviations, 'TID' stands for 'ter in die,' which means three times a day, and 'p.o.' stands for 'per os,' which means orally. Therefore, the correct administration schedule for the ampicillin capsule is three times a day orally. Choices B, C, and D are incorrect because they do not align with the prescribed frequency or route of administration specified in the order.

4. How many ounces are in 1 cup?

A. 8
B. 80
C. 800
D. 8000

Correct answer: A

Rationale: 1 cup is equivalent to 8 ounces. This conversion is commonly used in cooking and baking recipes, where precise measurements are crucial for the successful outcome of dishes. Knowing this conversion helps ensure that ingredients are accurately measured and the recipe turns out as intended. Choices B, C, and D are incorrect because they do not reflect the correct conversion between cups and ounces. 80, 800, and 8000 ounces are significantly higher quantities than what is found in 1 cup, which is 8 ounces.

5. What is required for effective hand washing?

A. Soap or detergent to promote emulsification
B. Hot water to destroy bacteria
C. A disinfectant to increase surface tension
D. All of the above

Correct answer: A

Rationale: To effectively wash hands, soap or detergent is essential as they help emulsify fats and oils, allowing them to be rinsed away. Hot water alone cannot effectively destroy bacteria, and a disinfectant is not typically required for routine hand washing.