ATI Perfusion Quizlet

Questions 43

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ATI Perfusion Quizlet Questions

Question 1 of 5

A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take?

Correct Answer: C

Rationale: The patient�€™s clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered.

Question 2 of 5

A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to

Correct Answer: D

Rationale: The patient's symptoms, back pain, and difficulty breathing after the transfusion indicate a possible acute hemolytic reaction, a severe transfusion reaction. The priority action in this situation is to discontinue the transfusion immediately to prevent further complications. Infusing normal saline helps maintain the patient's intravascular volume and prevent renal damage. Administering oxygen or obtaining a urine specimen is not the most urgent action and could delay essential treatment. Notifying the healthcare provider is important but should come after ensuring the patient's safety by stopping the blood transfusion.

Question 3 of 5

A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take?

Correct Answer: C

Rationale: The patient�€™s clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered.

Question 4 of 5

Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first?

Correct Answer: B

Rationale: The patient's young age and the presence of a nontender lump in the axilla raise concerns for possible lymphoma, which requires prompt evaluation and treatment. This patient should be seen first to rule out any serious underlying condition. Choice A is less urgent as yellowish eyes in sickle cell anemia may be due to jaundice but not necessarily an acute issue. Choice C, a 50-year-old with chronic fatigue related to early-stage chronic lymphocytic leukemia, is a known condition that can be managed on a routine basis. Choice D, a 19-year-old with hemophilia wanting to self-administer factor VII replacement, is important but less urgent compared to the potential lymphoma presentation in choice B.

Question 5 of 5

During a physical assessment, the nurse examines the lymph nodes of a patient. Which assessment finding would be of most concern to the nurse?

Correct Answer: A

Rationale: The correct answer is A. A 2-cm nontender supraclavicular node is of most concern because enlarged and nontender nodes in this area are highly suggestive of malignancies such as lymphoma. Choice B is less concerning as a 1-cm mobile and nontender axillary node is usually benign. Choice C, an inability to palpate any superficial lymph nodes, could be due to factors like obesity or edema, but it is not necessarily a cause for immediate concern. Choice D, firm inguinal nodes in a patient with an infected foot, may indicate a local reaction to infection rather than a systemic issue related to malignancy.

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