a nurse is assessing a client for signs of deep vein thrombosis dvt which of the following findings should the nurse look for
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN

1. A nurse is assessing a client for signs of deep vein thrombosis (DVT). Which of the following findings should the nurse look for?

Correct answer: A

Rationale: The correct answer is A: Swelling in the limb. Swelling, particularly in one limb, is a common sign of deep vein thrombosis (DVT) and should be assessed. This swelling is often accompanied by pain, redness, and warmth in the affected area. Choices B, C, and D are incorrect because decreased heart rate, increased appetite, and improved mobility are not typically associated with DVT. The main focus in assessing for DVT is recognizing the signs and symptoms related to venous thrombosis.

2. A healthcare provider is preparing to transfer a client from a chair to the bed. The client can bear partial weight and has upper body strength. Which device should the healthcare provider use?

Correct answer: B

Rationale: A stand-assist lift is the most suitable device for transferring a client who can bear partial weight and has upper body strength. This device provides support and assistance for the client to stand up and transfer safely. Choice A, a wheelchair, is not designed for this purpose and is used for mobility. Choice C, a transfer belt, is helpful for providing stability during transfers but may not be sufficient for a client with partial weight-bearing. Choice D, a slide board, is more suitable for transferring clients who are unable to bear weight and need assistance for lateral transfers.

3. A healthcare provider is educating a client about the use of montelukast. Which of the following should be included?

Correct answer: B

Rationale: The correct answer is B. Montelukast is a leukotriene receptor antagonist that is typically taken once daily in the evening for asthma management. Choice A is incorrect as montelukast is not used for acute asthma attacks but rather for the prevention of asthma symptoms. Choice C is also incorrect because montelukast can be taken with or without food. Choice D is misleading as all medications, including montelukast, have potential side effects.

4. A healthcare professional is preparing to administer a dose of potassium chloride. Which of the following actions should the healthcare professional take?

Correct answer: B

Rationale: The correct action when administering potassium chloride is to dilute the medication before administration. Potassium chloride is a highly concentrated solution that can cause irritation and potential complications if not properly diluted. Administering it rapidly (choice A) can lead to adverse effects. Giving it as a bolus (choice C) or administering it intramuscularly (choice D) are inappropriate routes for potassium chloride administration and can result in harm to the patient.

5. When teaching a client about the use of risperidone, which of the following should be included?

Correct answer: B

Rationale: The correct answer is B: 'Monitor for metabolic syndrome.' Risperidone is not an SSRI but an atypical antipsychotic. Choice A is incorrect. Choice C is also incorrect as risperidone, like any medication, can have side effects. Choice D is wrong because alcohol consumption should generally be avoided while taking risperidone. Educating clients about monitoring for metabolic syndrome, weight gain, and other potential side effects is crucial in managing their health effectively while on this medication.

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