ATI real life RN : GI Bleed 3.0 Test Questions and Answers
Graded A
Nurse Esther listens to Ms. Lieberman's B. ask Ms. Lieberman if she has experienced a
abdomen in all four quadrants and determines reaction with any previous blood transfusions
Ms. Lieberman's bowel sounds are hyperactive.
Listen to the 4 audio clips. which of the following C. ensure Ms. Lieberman's sister signs the
sounds is an expected finding for Ms. Lieberman: consent form
A, B, C, D - ANSWERS -C D. perform verifications process with an AP -
ANSWERS - B. ask Ms. Lieberman if she
has experienced a reaction with any previous
MS. Lieberman states she is feeling lightheaded blood transfusions
and dizzy. her skin color is pale. which of the
following should be Nurse Esther's priority rationale: a transfusion reaction can be caused
action? by the dvlpmt of antibodies to the donor
leukocytes. this reaction is more likely to occur
A. measure Ms. Lieberman's vs when a pt has had blood transfusions before as
B. finish obtaining the admin hx well as a hx of prior blood transfusion rx.
C. initiate oxygen at 2L/min via nasal cannula
D. elevate Ms. Lieberman's legs -
ANSWERS - A. measure Ms. Lieberman's Identify the correct sequence of actions for blood
vs administration after Nurse Esther performs hand
hygiene and applies gloves. (Move the steps to
the box on the right, placing them in the correct
Ms. Lieberman reports feeling worse and her order of performance. All steps must be used.) -
vital signs are: BP 94/56 mm Hg, pulse 110/min, ANSWERS - 1. Spike and prime the Y-set
RR 26/min, and SaO2 94%. Nurse Esther starts tubing with the 0.9% sodium chloride solution.
oxygen at 2 L/min. Which of the following should
be Nurse priority action? 2. Attach the tubing to the IV catheter and begin
to infuse the 0.9% sodium chloride solution.
A. recheck Ms. Lieberman's oxygen sat
B. check output from Ms. Lieberman's ostomy 3. Gently rotate the bag of packed RBCs.
C. lower the head of bed
D. send the AP to pick up blood - 4. Attach the packed RBCs bag to the Y-set
ANSWERS - C. lower the head of bed tubing.
5. Turn off the 0.9% sodium chloride solution.
Nurse Esther is preparing to administer a unit of
packed RBCs to Ms. Lieberman. Which of the 6. Begin to infuse the packed RBCs
following actions should Nurse Esther perform
prior to administering the blood?
Nurse Esther notes Ms. Lieberman is restless,
A. infuse 0.9% sodium chloride IV solution her face is flushed, and reports having a
remaining in the bag, prior to initiating the headache. VS: temp 38.8*C (101.8*F), pulse
transfusion 96/min, RR 22/min, and BP 103/60 mm Hg.
Which of the following is an appropriate action for
Nurse Esther to take?
1/3
Graded A
Nurse Esther listens to Ms. Lieberman's B. ask Ms. Lieberman if she has experienced a
abdomen in all four quadrants and determines reaction with any previous blood transfusions
Ms. Lieberman's bowel sounds are hyperactive.
Listen to the 4 audio clips. which of the following C. ensure Ms. Lieberman's sister signs the
sounds is an expected finding for Ms. Lieberman: consent form
A, B, C, D - ANSWERS -C D. perform verifications process with an AP -
ANSWERS - B. ask Ms. Lieberman if she
has experienced a reaction with any previous
MS. Lieberman states she is feeling lightheaded blood transfusions
and dizzy. her skin color is pale. which of the
following should be Nurse Esther's priority rationale: a transfusion reaction can be caused
action? by the dvlpmt of antibodies to the donor
leukocytes. this reaction is more likely to occur
A. measure Ms. Lieberman's vs when a pt has had blood transfusions before as
B. finish obtaining the admin hx well as a hx of prior blood transfusion rx.
C. initiate oxygen at 2L/min via nasal cannula
D. elevate Ms. Lieberman's legs -
ANSWERS - A. measure Ms. Lieberman's Identify the correct sequence of actions for blood
vs administration after Nurse Esther performs hand
hygiene and applies gloves. (Move the steps to
the box on the right, placing them in the correct
Ms. Lieberman reports feeling worse and her order of performance. All steps must be used.) -
vital signs are: BP 94/56 mm Hg, pulse 110/min, ANSWERS - 1. Spike and prime the Y-set
RR 26/min, and SaO2 94%. Nurse Esther starts tubing with the 0.9% sodium chloride solution.
oxygen at 2 L/min. Which of the following should
be Nurse priority action? 2. Attach the tubing to the IV catheter and begin
to infuse the 0.9% sodium chloride solution.
A. recheck Ms. Lieberman's oxygen sat
B. check output from Ms. Lieberman's ostomy 3. Gently rotate the bag of packed RBCs.
C. lower the head of bed
D. send the AP to pick up blood - 4. Attach the packed RBCs bag to the Y-set
ANSWERS - C. lower the head of bed tubing.
5. Turn off the 0.9% sodium chloride solution.
Nurse Esther is preparing to administer a unit of
packed RBCs to Ms. Lieberman. Which of the 6. Begin to infuse the packed RBCs
following actions should Nurse Esther perform
prior to administering the blood?
Nurse Esther notes Ms. Lieberman is restless,
A. infuse 0.9% sodium chloride IV solution her face is flushed, and reports having a
remaining in the bag, prior to initiating the headache. VS: temp 38.8*C (101.8*F), pulse
transfusion 96/min, RR 22/min, and BP 103/60 mm Hg.
Which of the following is an appropriate action for
Nurse Esther to take?
1/3
