a nurse is preparing to administer a blood transfusion to a client which of the following actions should the nurse take first
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN

1. A healthcare professional is preparing to administer a blood transfusion to a client. Which of the following actions should the healthcare professional take first?

Correct answer: D

Rationale: Verifying the client's identity is the first crucial action the healthcare professional should take before administering a blood transfusion. This step ensures that the right blood is given to the right client, helping prevent errors. Obtaining vital signs, ensuring IV access, and priming IV tubing are important steps in the process but verifying the client's identity takes precedence for patient safety and accurate care delivery.

2. A client has a new prescription for ferrous sulfate. Which of the following instructions should the nurse include in the teaching?

Correct answer: C

Rationale: The correct instruction is to take ferrous sulfate with orange juice to increase absorption because the vitamin C content in orange juice enhances iron absorption. Choice A is incorrect because ferrous sulfate should be taken with food to reduce gastrointestinal side effects. Choice B is incorrect because milk can decrease iron absorption. Choice D is incorrect because antacids can reduce the absorption of ferrous sulfate.

3. A nurse in an emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the nurse take first?

Correct answer: D

Rationale: In a client experiencing drooling and hoarseness following a burn injury, the priority action for the nurse is to administer 100% humidified oxygen. This is crucial to maintain the airway and address respiratory distress, which takes precedence over obtaining an ECG, collecting blood for ABG analysis, or inserting an IV catheter. Providing oxygen therapy is essential in ensuring the client's oxygenation and respiratory function are optimized in this emergency situation.

4. A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?

Correct answer: A

Rationale: Corrected Rationale: Weak femoral pulses are an expected finding in an infant with coarctation of the aorta. The narrowing of the aorta leads to decreased blood flow to the lower extremities, resulting in weak or absent femoral pulses. Frequent nosebleeds (Choice B) are not typically associated with coarctation of the aorta. Upper extremity hypotension (Choice C) is not a common finding in coarctation of the aorta; instead, blood pressure is usually elevated in the upper extremities. Increased intracranial pressure (Choice D) is not directly related to coarctation of the aorta.

5. What is the priority nursing action for a patient with respiratory distress?

Correct answer: A

Rationale: The priority nursing action for a patient with respiratory distress is to administer oxygen. Oxygen therapy is crucial in improving oxygenation levels and relieving respiratory distress, making it the top priority intervention. Repositioning the patient, administering bronchodilators, or providing chest physiotherapy may be necessary interventions depending on the underlying cause, but ensuring adequate oxygen supply should take precedence in addressing respiratory distress.

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