which intervention should the nurse implement for a patient receiving a blood transfusion
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Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. What intervention should the nurse implement for a patient receiving a blood transfusion?

Correct answer: B

Rationale: The correct intervention for a patient receiving a blood transfusion is to monitor the patient for signs of circulatory overload. This is crucial to prevent fluid overload, which can lead to serious complications. Administering antihistamines is not a routine intervention during blood transfusions unless the patient shows signs of an allergic reaction. Ensuring the completion of the blood transfusion within a specific time frame is not as critical as monitoring for circulatory overload. Checking vital signs every 30 minutes is essential, but the specific focus should be on monitoring for signs of circulatory overload.

2. What are the nursing priorities when caring for a patient with a newly placed peripherally inserted central catheter (PICC)?

Correct answer: A

Rationale: The correct answer is A: Performing sterile dressing changes. When caring for a patient with a newly placed PICC line, one of the nursing priorities is to ensure proper care of the insertion site by performing sterile dressing changes. This helps prevent infections and maintain the integrity of the line. While educating the patient on PICC line care, flushing the PICC line as prescribed, and inspecting the insertion site for signs of infection are important aspects of care, the priority immediately after insertion is to maintain the sterility of the site through proper dressing changes.

3. A client has bilateral eye patches following an injury. When the client's food tray arrives, which of the following interventions should the nurse take to promote independence in eating?

Correct answer: D

Rationale: Describing the location of food on the tray helps promote independence for the client with bilateral eye patches. By providing clear instructions on where the food is placed, the client can independently locate and consume their meal. Option A is incorrect as physically placing the client's hands on the tray does not encourage independence. Option B is unnecessary unless there are specific dietary restrictions indicated. Option C does not promote the client's independence and should be avoided unless absolutely necessary.

4. Which finding in a postoperative patient requires immediate intervention by the nurse?

Correct answer: D

Rationale: In a postoperative patient, an oxygen saturation level of 88% on room air indicates a significant drop below the normal range, suggesting potential respiratory distress. This finding requires immediate intervention by the nurse to ensure the patient receives adequate oxygenation. A heart rate of 88 beats per minute is within the normal range, making it a less concerning finding. A blood pressure of 130/80 mmHg falls within the normal range for blood pressure and does not require immediate intervention. Crackles heard in the lung bases may indicate fluid accumulation but may not always require immediate intervention unless accompanied by other concerning signs or symptoms.

5. A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?

Correct answer: A

Rationale: The correct answer is A: Self-report of pain. Pain is a subjective experience, and the most reliable way to assess it is through the client's self-report. While nonverbal behaviors and vital signs can provide additional information, they are not as reliable as the client's own report of pain. The severity of the condition may influence the experience of pain but is not a direct indicator of the client's pain level.

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