a nurse is preparing to administer a blood transfusion what is the first action

ATI LPN

ATI PN Comprehensive Predictor 2024

1. A nurse is preparing to administer a blood transfusion. What is the first action?

A. Administer the blood through an IV push
B. Verify the client's blood type before starting the transfusion
C. Warm the blood to body temperature before administration
D. Ensure the client eats before starting the transfusion

Correct answer: B

Rationale: The correct first action when preparing to administer a blood transfusion is to verify the client's blood type before starting the transfusion. This step is crucial to prevent transfusion reactions and complications. Option A is incorrect because blood transfusions should not be administered through an IV push due to the risk of rapid infusion and adverse reactions. Option C is incorrect because blood should be transfused at room temperature, not body temperature. Option D is incorrect because it is not necessary for the client to eat before a blood transfusion.

2. How should a healthcare provider manage a patient with sepsis?

A. Administer IV antibiotics
B. Monitor vital signs
C. Administer fluids
D. All of the above

Correct answer: D

Rationale: Managing a patient with sepsis requires a multi-faceted approach. Administering IV antibiotics is crucial to combat the underlying infection. Monitoring vital signs such as heart rate, blood pressure, respiratory rate, and temperature helps assess the patient's response to treatment and identify any deterioration. Administering fluids is essential to maintain adequate blood pressure and organ perfusion. Therefore, all the options are integral components of sepsis management, making 'All of the above' the correct answer. Choices A, B, and C are all essential in the comprehensive care of a patient with sepsis. Omitting any of these aspects can lead to suboptimal outcomes, as each plays a critical role in addressing different aspects of sepsis management.

3. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

A. A client who was just given a glass of orange juice for a low blood glucose level.
B. A client who is scheduled for a procedure in 1 hr.
C. A client who has 100 mL fluid remaining in his IV bag.
D. A client who received a pain medication 30 min ago for postoperative pain.

Correct answer: A

Rationale: The client with low blood glucose needs immediate assessment to ensure that the orange juice has corrected the hypoglycemia. Monitoring the effectiveness of the intervention for low blood glucose is the priority. The other options, such as a client scheduled for a procedure in 1 hour, a client with fluid remaining in the IV bag, and a client who received pain medication 30 minutes ago, do not require immediate assessment like the client with low blood glucose.

4. A nurse is collecting data from a client who delivered a full-term newborn 16 hr ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?

A. Administer oxytocin
B. Perform fundal massage
C. Administer IV fluids
D. Call the provider

Correct answer: B

Rationale: Performing fundal massage is the priority action in this scenario. Fundal massage helps contract the uterus, which is essential in reducing excessive lochia postpartum. Administering oxytocin may be indicated later, but fundal massage should be the initial intervention to address the issue. Administering IV fluids may not directly address the cause of excessive lochia, and calling the provider should come after implementing immediate nursing interventions.

5. What are the key interventions for managing a patient with asthma?

A. Administer bronchodilators and monitor oxygen levels
B. Encourage deep breathing exercises
C. Provide corticosteroids and monitor for respiratory distress
D. Provide antihistamines and monitor blood pressure

Correct answer: A

Rationale: The correct answer is A: Administer bronchodilators and monitor oxygen levels. Asthma management involves using bronchodilators to help open the airways and improve breathing. Monitoring oxygen levels is essential to ensure the patient is getting enough oxygen. Choice B, encouraging deep breathing exercises, can be helpful for some respiratory conditions but is not a key intervention for managing an acute asthma attack. Choice C, providing corticosteroids and monitoring for respiratory distress, is important for long-term asthma management and severe exacerbations but is not the immediate key intervention during an acute attack. Choice D, providing antihistamines and monitoring blood pressure, is not typically indicated for asthma management as asthma is primarily an airway disease, not a histamine-mediated condition.