ACSI ATI

A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan?

Apply pressure to needlestick sites for 10 min.

A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the nurse plan to take?

Check the client's vital signs every hour during the transfusion.

A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions?

hemolytic

A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first?

place the client in sitting position

nurse is planning a menu for a client who has folic acid deficiency anemia. Which of the following foods should the nurse include as high in folate?

1/4 cup asparagus

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?

"The purpose of this device is to immobilize the cervical spine."

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

Bladder distended

A nurse is admitting a child who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate?

Bleeding

A nurse is assessing a client who is receiving a platelet transfusion. Which of the following findings is an adverse effect of the transfusion?

Chills

A nurse is reviewing the laboratory results of a client who has acute leukemia and received an aggressive chemotherapy treatment 10 days ago. Which of the following hematologic laboratory values should the nurse expect? (Select all that apply.)

Decreased platelet count Decreased leukocyte count Decreased erythrocyte count

A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload?

Dyspnea JVD Confusion

A nurse is assessing a client who is postoperative and has anemia due to excess blood loss during surgery. The nurse should expect which of the following findings?

Fatigue

A nurse is caring for a client who is recievig a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?

Hemolytic

A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings is a manifestation of hemolytic transfusion reaction?

Report low back pain

A nurse is reviewing a client's CBC findings and discovers that the client's platelet count is 9,000/mm. The nurse should monitor the client for which of the following conditions?

Spontaneous bleeding

A nurse is administering platelets to a client who reports having lower back pain and feeling chilled and itchy. Which of the following actions should the nurse take first?

Stop the infusion

nurse is teaching a client who has iron deficiency anemia about ferrous sulfate. Which of the following instructions should the nurse include in the teaching?

Take between meals

A nurse is providing teaching for a client who has anemia and a new prescription for ferrous sulfate liquid. Which of the following instructions should the nurse provide?

Take the medication with orange juice to enhance absorption.

A charge nurse is supervising a newly licensed nurse care for a client who is receiving a transfusion of packed RBC. The nurse suspects a possible hemolytic reaction. After stopping the blood transfusion, which of the following actions by the new nurse requires intervention by the charge nurse?

The nurse starts the transfusion of another unit of blood product. A nurse is selecting staff member

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? Select all that apply.

Hypotension Hyperthermia weakened gag reflex

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

High fowlers

A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?

Pain

A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses?

Uricaria

A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following

Urticaria