a nurse is assessing a client with deep vein thrombosis dvt which of the following interventions should the nurse include in the plan of care
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment Form B

1. A healthcare professional is assessing a client with deep vein thrombosis (DVT). Which of the following interventions should the healthcare professional include in the plan of care?

Correct answer: C

Rationale: Elevating the affected leg is a crucial intervention in the care of a client with deep vein thrombosis (DVT). This position helps reduce swelling and promotes venous return, which can alleviate symptoms associated with DVT. Applying ice packs (Choice A) may worsen the condition by causing vasoconstriction. Encouraging ambulation (Choice B) can dislodge the clot and lead to fatal complications. Massaging the affected area (Choice D) can also dislodge the clot and is contraindicated in DVT.

2. A healthcare provider is educating a patient on the use of alendronate. Which of the following should be included?

Correct answer: B

Rationale: The correct answer is B: 'Take it once a week.' Alendronate is typically taken once a week to treat osteoporosis. It should be taken on an empty stomach in the morning with a full glass of water. Choice A is incorrect because alendronate should be taken on an empty stomach, not with food. Choice C is incorrect because alendronate should be taken in the morning, not at bedtime. Choice D is unrelated to alendronate use and not a common side effect associated with this medication.

3. A client has been prescribed metformin. What should be included in the teaching?

Correct answer: B

Rationale: The correct answer is to take metformin with food. This is important to minimize gastrointestinal side effects and improve absorption. Choice A is incorrect as metformin is not typically associated with weight gain. Choice C is wrong as metformin is not an insulin but a medication that helps control blood sugar levels. Choice D is also incorrect as metformin is not known to cause hyperglycemia.

4. A healthcare professional is assessing a client with heart failure. Which of the following signs should the healthcare professional monitor for?

Correct answer: A

Rationale: In heart failure, the accumulation of fluid can lead to peripheral edema, which is swelling in the extremities. This is a common sign that healthcare professionals should monitor for. While tachycardia (increased heart rate), bradycardia (decreased heart rate), and hypotension (low blood pressure) can also occur in heart failure, they are not the primary signs typically associated with this condition. Therefore, peripheral edema is the most relevant sign to monitor in this case.

5. A nurse is assessing a client who is 24 hours postpartum. Which of the following findings should the nurse report to the healthcare provider?

Correct answer: B

Rationale: A perineal pad saturated in 15 minutes is a sign of excessive postpartum bleeding, which requires immediate medical attention to prevent postpartum hemorrhage. The other findings are normal postpartum occurrences. A firm and midline uterine fundus indicates proper involution, breast tenderness during breastfeeding is common due to engorgement, and a temperature of 100.4°F is considered within the normal range for the postpartum period.

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