a nurse is caring for a client who has deep vein thrombosis dvt of the left lower extremity which of the following actions should the nurse take
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment A

1. A nurse is caring for a client who has deep vein thrombosis (DVT) of the left lower extremity. Which of the following actions should the nurse take?

Correct answer: D

Rationale: The correct answer is to withhold heparin IV infusion. The nurse should withhold heparin if there are signs of complications, such as bleeding, or if there are contraindications to continuing anticoagulation therapy. Positioning the client with the affected extremity higher than the heart helps reduce swelling and improve blood flow. Administering acetaminophen for pain management can be appropriate, but it is not the priority in this situation. Massaging the affected extremity can dislodge the clot and lead to serious complications, so it should be avoided.

2. A nurse is caring for a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?

Correct answer: A

Rationale: Lip-smacking is a symptom of tardive dyskinesia, a long-term side effect of antipsychotic medications like haloperidol, characterized by involuntary movements of the face and jaw. Agranulocytosis (Choice B) is a rare but serious side effect of some medications, characterized by a dangerously low white blood cell count. Clang association (Choice C) is a thought disorder characterized by the association of words based on sound rather than meaning. Alopecia (Choice D) refers to hair loss, which is not a known long-term side effect of haloperidol.

3. A client at 28 weeks of gestation is experiencing preterm labor. Which of the following medications should the nurse plan to administer?

Correct answer: B

Rationale: Nifedipine is the correct choice in this scenario. It is a calcium channel blocker that helps suppress uterine contractions and halt preterm labor. Nifedipine is commonly used to manage preterm labor in pregnant women by relaxing the smooth muscle of the uterus. Oxytocin (Choice A) is used to induce or augment labor, not to inhibit contractions. Dinoprostone (Choice C) and Misoprostol (Choice D) are prostaglandins used for cervical ripening and induction of labor, not for stopping preterm labor.

4. A nurse is preparing to administer medications to a client who is NPO and has an NG tube for suction. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take when administering medications to a client with an NG tube for suction who is NPO is to clamp the NG tube for 30 minutes after medication administration. This is done to allow for proper absorption of the medications before resuming suction. Choice A is incorrect because medications should not be mixed with enteral feedings as it may affect the drug's effectiveness. Choice C is incorrect as medications should not be inserted directly into the NG tube without dilution, as this can cause clogging or affect the tube. Choice D is incorrect because connecting the NG tube to continuous suction after medication administration can interfere with the absorption of the medications.

5. A nurse is checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia?

Correct answer: B

Rationale: The correct answer is B. A urine specific gravity of 1.001 is low and indicates dilute urine, which is a sign of fluid overload (hypervolemia). Choice A, serum sodium 138 mEq/L, is within the normal range and does not indicate hypervolemia. Choice C, serum calcium 10 mg/dL, is not typically used to diagnose hypervolemia. Choice D, urine pH 6, is also not a specific indicator of hypervolemia.

Similar Questions

A client with a new prescription for an albuterol metered-dose inhaler is being taught by a nurse. Which of the following instructions should the nurse include in the teaching?
A nurse is caring for a client with a history of hypertension. Which of the following should the nurse monitor?
A healthcare provider is preparing to administer a dose of clindamycin. Which of the following should the provider assess first?
A client scheduled for an electroencephalogram (EEG) is receiving teaching from a nurse. Which statement by the client indicates an understanding of the teaching?
While assessing the IV infusion site of a client who reports pain at the site, a nurse notes redness and warmth along the vein. What should the nurse do?

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