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

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN

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

A. Check the client's identification bracelet.
B. Obtain the client's vital signs.
C. Initiate the transfusion slowly over the first 15 minutes.
D. Verify the client's blood type and Rh factor.

Correct answer: D

Rationale: The correct answer is to verify the client's blood type and Rh factor first before administering blood. This is crucial to ensure compatibility and prevent transfusion reactions. Checking the client's identification bracelet (Choice A) is important but should come after verifying blood type. Obtaining vital signs (Choice B) and initiating the transfusion slowly (Choice C) are important steps but verifying blood type is the priority to ensure safe blood administration.

2. A nurse is caring for a client who has acute pancreatitis. Which of the following laboratory results should the nurse expect to be elevated?

A. Serum creatinine.
B. Amylase.
C. Hemoglobin.
D. Blood glucose.

Correct answer: B

Rationale: The correct answer is B: Amylase. Amylase is typically elevated in clients with acute pancreatitis due to inflammation of the pancreas. Elevated serum creatinine levels are more indicative of kidney dysfunction rather than pancreatitis. Hemoglobin levels are not directly related to pancreatitis. While blood glucose levels can be affected by pancreatitis, they are not typically the primary laboratory result expected to be elevated in this condition.

3. Which diagnostic test is used to confirm tuberculosis (TB) infection?

A. Chest X-ray
B. Sputum culture
C. Skin test (Mantoux)
D. MRI

Correct answer: C

Rationale: The Mantoux skin test, also known as the Tuberculin Skin Test (TST), is used to confirm tuberculosis (TB) infection. This test involves injecting a small amount of tuberculin protein derivative under the top layer of the skin and then evaluating the immune system's response to the protein. A positive reaction indicates exposure to the TB bacteria. Chest X-rays are used to detect abnormalities in the lungs caused by TB but are not confirmatory. Sputum culture is used to identify the presence of TB bacteria in the sputum. MRIs are not typically used as a primary diagnostic tool for TB.

4. How should a healthcare provider care for a patient with a tracheostomy?

A. Clean the tracheostomy site daily
B. Change the tracheostomy ties daily
C. Suction the tracheostomy regularly
D. Provide humidified oxygen

Correct answer: C

Rationale: Suctioning the tracheostomy regularly is crucial in caring for a patient with a tracheostomy as it helps keep the airway clear of secretions, preventing blockages and potential complications. Cleaning the tracheostomy site daily is important for hygiene but not as critical as regular suctioning. Changing the tracheostomy ties daily may not be necessary unless soiled or loose. Providing humidified oxygen may be part of the care plan but is not as directly related to maintaining the tracheostomy patency as suctioning.

5. A nurse is caring for a client who has cirrhosis. Which of the following findings should the nurse expect?

A. Decreased bilirubin levels
B. Decreased prothrombin time
C. Decreased albumin levels
D. Increased prothrombin time

Correct answer: D

Rationale: In clients with cirrhosis, the liver is unable to produce clotting factors efficiently, leading to impaired clotting function. Therefore, an increased prothrombin time is expected in cirrhosis. Choices A, B, and C are incorrect. Decreased bilirubin levels are not typically seen in cirrhosis; prothrombin time is usually increased, not decreased; and albumin levels are often decreased in cirrhosis due to reduced synthetic liver function.