Clotting ATI; Level 4 Exam Elaboration |UPDATED!!!| #Latest

Clotting ATI; Level 4 Exam Elaboration |UPDATED!!!| #Latest 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? *Ans* Stop the infusion. The greatest risk to this client is injury from a transfusion reaction, which can be more harmful if the client receives more of the blood product. Therefore, the first action the nurse should take is to stop the infusion. A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse? *Ans* The posterior tibial pulse is located on the inner ankle, one-third of the way along a line between the tip of the medial malleolus (end of the tibia) and the point of the heel. It is most easily palpated about 2.5 cm higher, where it runs behind the medial malleolus. A nurse is assessing a client who is receiving a platelet transfusion. Which of the following findings is an adverse effect of the transfusion? *Ans* Chills Severe chills is an adverse effect of a platelet transfusion. The client might require premedication of diphenhydramine and acetaminophen to reduce this reaction. is an adverse effect of a platelet transfusion. *Ans* Fever is a manifestation of a nonhemolytic transfusion reaction. *Ans* Anxiety is a manifestation of a hemolytic transfusion reaction. *Ans* Tachycardia A nurse is teaching a newly licensed nurse about evaluating a cardiac rhythm. Which of the following options should the nurse identify as the P wave in the ECG complex? *Ans* The nurse should identify the P wave as the initial wave of the sinus rhythm. The P wave is an electrical representation of atrial depolarization. A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include? *Ans* "You might have to stop taking this medication 5 days before any planned surgeries." Clopidogrel inhibits platelet aggregation and can cause bleeding. The client should report taking this medication to providers to determine whether to discontinue the medication prior to elective procedures to reduce the risk for bleeding. A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect? *Ans* Excessive thrombosis and bleeding The nurse should expect excessive thrombosis and bleeding of mucous membranes because both DIC impairs both coagulation and anti-coagulation pathways. A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mmHg. Which of the following actions should the nurse take first? *Ans* Stop the infusion of blood