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ATI COMPREHENSIVE 2019 C

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68. A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take? P. 249 med surg pdf a. Check the client’s vital signs from the previous shift prior to the initiation of the transfusionassess prior to infusion then be with them for first 15 - 30 minutes. b. Set the IV infusion pump to administer the blood over 6 hr c. Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion- d. Administer the blood via a 21-gauge IV needle 69. A nurse is caring for a client who is dissatisfied with the care from the provider and decides to leave the facility against medical advice. After notifying the provider, which of the following actions is appropriate for the nurse to take? a. Summon a security guard b. Explain the risks of leaving c. Complete an incident report d. Notify a social worker Rationale: 70. A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse? a. “I try to respond to the baby quickly .” b. “I think the baby should be sleeping through the night by now. c. “I have several friends who come by to help out with the baby.” d. “I want to meet other parents to see if they are going through the same thing.”71. A nurse is caring for an infant who has gastroenteritis. Which of the following assessments should the nurse report to the provider? a. Temperature 38 C(100.4 F) and pulse rate 124/min p b. Decreased appetite and irritability c. Pale and 24-hour fluid deficit of 30 mL d. Sunken fontanels and dry mucous membranes 72. A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding, The nurse does not speak the same language as the client . The client partner and a 10 year old child are accompanying her. Which of the following actions should the nurse take to gather the clients information? Request a female translator interpreter through the facility a. Ask a student nurse who speaks the same language to translate b. Have the child translate c. Allow the clients partner to translate 73. A nurse is caring for a client who has pernicious anemia, Which of the following laboratory values should the nurse evaluate effectiveness of the treatment ? A. Folate level B. INR level C. Vitamin b12 level D. Creatinine level 74. A nurse is assigning tasks to assistive personnel(AP). Which of the following tasks should the nurse assign to the AP? a. Suction a new tracheostomy b. Remove an NG tube c. Perform post mortem care d. Change the dressing on an implanted central venous access device

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