ATI Detailed Answer Key, 2024 BMS Quiz Week 8 with 100%Verified Answers.

ATI Detailed Answer Key, 2024 BMS Quiz Week 8 with 100%Verified Answers. 1. A nurse is reviewing the laboratory results of an adolescent female client and notes a WBC count of 16,000/mm³ with increased immature neutrophils (bands) and normal monocytes. Which of the following is the appropriate analysis of the results? A. An acute infectious process Rationale: The white blood cell (WBC) count is greatly elevated; however, even more telling is the elevated neutrophil count, sometimes referred to as a "shift to the left." So, with the combined information from the elevated WBC count indicating infection or inflammation and the elevated neutrophil count indicating an acute process, the appropriate analysis is that the client has an acute infectious process. B. Neutropenia Rationale: Neutropenia is a low neutrophil count which places the client at increased risk for infection. C. Allergic reaction Rationale: A client who is having an allergic reaction will have increased numbers of eosinophils. These cells increase during hypersensitivity reactions and serve to neutralize histamine. D. A resolving inflammatory process Rationale: The white blood cell (WBC) count is elevated indicating infection. However, when combined with the elevated bands, sometimes referred to as a "shift to the left," this indicates an acute, rather than a resolving, process. In a resolving or chronic process, the nurse would expect to see a greater elevation in the monocytes. 2. A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client? A. 1.5 oz raisins Rationale: The nurse should recommend that the client eat dried fruits, such as raisins, to increase iron intake. However, a small box (1.5 oz) of raisins contains only 0.81 mg of iron. B. 8 oz black tea Rationale: The nurse should recommend the client avoid tea as it contains tannin, a product that inhibits the absorption of iron. C. 1 cup canned black beans Rationale: The nurse should recommend canned black beans as they contain the greatest amount of iron at 4.56 mg per serving. D. 8 oz whole milk Rationale: The nurse should recommend the client avoid drinking milk in conjunction with iron tablets or iron-rich foods. The calcium in the milk product limits the absorption of the iron. Instead the nurse could recommend the client take the iron product with orange juice as the ascorbic acid (vitamin C) contained in the orange juice increases the absorption of iron-rich foods. Created on: 04 /18/2024 Page 1 Detailed Answer Key BMS Quiz Week 8 Day 3. 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? A. Febrile Rationale: A client having a febrile transfusion reaction exhibits tachycardia along with fever, but not headache and low back pain. B. Hemolytic Rationale: In addition to tachycardia, headache, and low back pain, a hemolytic reaction can also cause fever, chills, hypotension, possible chest pain, and hemoglobinuria. C. Allergic Rationale: A client having an allergic transfusion reaction exhibits tachycardia—in addition to urticaria, itching, and bronchospasm—without headache or low back pain. D. Bacterial Rationale: A client having a bacterial transfusion reaction exhibits tachycardia—in addition to hypotension, fever, and chills—but not headache and low back pain. 4. A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first? A. Turn the client's head to the side. Rationale: The first action the nurse should take when using the airway, breathing, circulation approach to client care is to turn the client's head to the side. This action keeps the client's airway clear of secretion to prevent aspiration. B. Check the client's motor strength. Rationale: The nurse should check the client's motor strength as part of a neurovascular assessment following the seizure; however, there is another action the nurse should take first. C. Loosen the clothing around the client's waist. Rationale: The nurse should loosen the clothing around the client's waist to protect the client from injury; however, there is another action the nurse should take first. D. Document the time the seizure began. Rationale: The nurse should document the time the seizure began and ended to provide information to the provider about the severity of the seizure; however, there is another action the nurse should take first. Created on: 04 /18/2024 Page 2 Detailed Answer Key BMS Quiz Week 8 Day 5. A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level? A. pulse and blood pressure findings Rationale: The nurse should assess the client's pain level routinely along with vital signs. A pain assessment should also be completed if the client has a change in condition, such as a new onset of chest pain, or following a procedure which can be uncomfortable for the client, such as x-rays which require the client to lay on a hard surface for extended periods of time. A hierarchical method of pain assessment is recommended when caring for clients who may have difficulty expressing themselves. Although vital signs can be used as a physiologic indicator, monitoring them is an objective method of evaluating pain and may not be a reliable means of assessing pain levels. Evidence-based practice indicates the nurse should use a different parameter first. B. behavioral indicators and effect Rationale: A hierarchical method of pain assessment is recommended when caring for clients who may have difficulty expressing themselves. Although behavioral indicators can be used, the nurse should recognize that pain behaviors are unique to each patient. Evidence-based practice indicates the nurse should use a different parameter first. C. scheduled treatments and client illness Rationale: A hierarchical method of pain assessment is recommended when caring for clients who may have difficulty expressing themselves. Although treating a client based upon the client’s condition or based upon the client’s scheduled, potentially painful procedure will yield effective results at assessing pain levels, evidence-based practice indicates the nurse should use a different parameter first. D. a self-report pain rating scale Rationale: Expressive aphasia results from damage to an area of the frontal lobe and is a motor speech problem. The client who has expressive aphasia is able to understand what is said but is unable to communicate verbally. However, this does not necessarily mean that a client is unable to reliably report pain. Evidence-based practice indicates the nurse should first attempt to obtain the client’s self- report of pain. When assessing a client for pain, the nurse should utilize the hierarchy of pain measures which begins with self-report. It is always better to use a subjective method, such as a client report, instead of an objective method, such as something that is observable by the nurse, which is much less reliable.