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. During the assessment of a client receiving packed RBCs, which finding indicates fluid overload?

A. Low back pain.
B. Dyspnea.
C. Hypotension.
D. Thready pulse.

Correct answer: B

Rationale: Dyspnea is a key finding indicating fluid overload in a client receiving packed RBCs. Fluid overload can lead to pulmonary edema, causing difficulty breathing or shortness of breath (dyspnea). Low back pain is not typically associated with fluid overload but can be more related to musculoskeletal issues. Hypotension and thready pulse are more indicative of hypovolemia (low fluid volume), not fluid overload.

3. What is the initial technique used when examining a client's abdomen?

A. Palpation
B. Auscultation
C. Percussion
D. Inspection

Correct answer: D

Rationale: When examining a client's abdomen, the initial technique used is inspection. Inspection involves visually assessing the abdomen for any abnormalities, such as distention, scars, or rashes. This step allows the healthcare provider to gather valuable information before proceeding to other examination techniques like palpation, auscultation, and percussion. Palpation, auscultation, and percussion are secondary techniques used after visual inspection to further assess the abdomen for specific findings. Palpation involves feeling the abdomen for masses or tenderness, auscultation is listening for bowel sounds, and percussion is tapping the abdomen to assess for areas of dullness or resonance.

4. When a client is comatose and has advance directives stating a desire to avoid life-sustaining measures, but the family wants these measures, what action should the nurse take?

A. Arrange for an ethics committee meeting to address the family's concerns.
B. Support the family's decision and initiate life-sustaining measures.
C. Complete an incident report.
D. Encourage the family to contact an attorney.

Correct answer: A

Rationale: In this scenario, the nurse should prioritize the client's wishes as outlined in the advance directives. By arranging for an ethics committee meeting, the nurse can facilitate discussions between the family and healthcare team to ensure that the client's wishes are respected while addressing the concerns of the family. This approach promotes ethical decision-making and collaborative communication among all involved parties, ultimately aiming to provide the best possible care for the client while considering their autonomy and preferences.

5. Which of the following substances increase the amount of urine produced?

A. Caffeine-containing drinks, such as coffee and cola
B. Beets
C. Urinary analgesics
D. Kaolin with pectin (Kaopectate)

Correct answer: A

Rationale: Caffeine is a diuretic, which means it increases urine production by promoting the excretion of water from the body through the kidneys. Therefore, substances like caffeine-containing drinks, such as coffee and cola, can lead to an increase in the amount of urine produced.