a nurse is caring for a client who has a deep vein thrombosis dvt which of the following interventions should the nurse include in the plan of care
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment B Quizlet

1. A nurse is caring for a client who has a deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?

Correct answer: B

Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to apply warm, moist compresses to the affected leg. This helps alleviate pain and improve circulation in the affected area, aiding in the treatment of DVT. Encouraging the client to ambulate frequently (Choice A) is contraindicated as it can dislodge the clot and lead to complications. Massaging the affected leg (Choice C) is also contraindicated as it can dislodge the clot and potentially cause an embolism. Placing the client in a supine position (Choice D) is not specifically indicated for DVT treatment; elevation of the affected leg is preferred over placing the client completely supine.

2. A client is prescribed warfarin for anticoagulation. Which of the following laboratory values should the nurse monitor?

Correct answer: A

Rationale: The correct answer is A: PT and INR. Warfarin is an anticoagulant that affects the clotting mechanism by inhibiting vitamin K-dependent clotting factors. The PT (Prothrombin Time) and INR (International Normalized Ratio) are specific laboratory values used to monitor the effectiveness and safety of warfarin therapy. These values help healthcare providers adjust the warfarin dosage to maintain the desired level of anticoagulation. Choices B, C, and D are incorrect because blood glucose levels, complete blood count (CBC), and platelet count are not directly monitored to assess the effects of warfarin therapy.

3. A charge nurse is planning care for a group of patients on a med-surg unit. What task should the nurse delegate to an assistive personnel?

Correct answer: A

Rationale: The correct answer is A because assistive personnel can be assigned to measure and document urinary output, a routine task within their scope of practice. Administering medications (choice B) requires a higher level of training and should be done by licensed nurses. Reinforcing patient education (choice C) involves providing information and ensuring patient understanding, which is typically done by licensed healthcare providers. Initiating a care plan (choice D) involves critical thinking and assessment skills, which are beyond the scope of practice for assistive personnel.

4. A nurse is caring for a client recovering from bowel surgery who has a nasogastric (NG) tube connected to low intermittent suction. Which of the following assessment findings should indicate to the nurse that the NG tube may not be functioning properly?

Correct answer: C

Rationale: Abdominal rigidity can indicate a serious complication, such as a blockage or infection, requiring immediate intervention to determine if the NG tube is functioning properly. Choices A, B, and D are not indicative of a malfunctioning NG tube. Greenish-yellow drainage fluid may be normal, an aspirate pH of 3 is within the expected range for gastric contents, and air bubbles in the NG tube are not abnormal as long as they are moving.

5. Before administering blood products, which action should be taken?

Correct answer: A

Rationale: Before administering blood products, assessing the patient’s temperature is crucial. This action provides baseline data to detect any febrile reactions during or after the transfusion. Fever may indicate a transfusion reaction, so continuous monitoring of vital signs is essential throughout the procedure. Documenting the patient’s response (choice B) is important but comes after assessing the temperature. Priming IV tubing with 0.45% sodium chloride (choice C) is not directly related to the initial action required before administering blood products. Administering epinephrine (choice D) is not indicated unless there is a severe allergic reaction, which is not the standard initial step before blood product administration.

Similar Questions

A nurse is assessing a client with chronic kidney disease. Which of the following findings should the nurse monitor?
A nurse is teaching a client about the use of pantoprazole. Which of the following should be included?
A nurse is assessing a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect?
A patient is scheduled for cataract surgery but decides to cancel, stating 'I see just fine.' Which of the following responses should the nurse make?
A nurse in the emergency department is caring for a patient who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the patient’s care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses