a nurse is caring for a client who is at risk for developing deep vein thrombosis dvt which of the following actions should the nurse take
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Nursing Elites

ATI RN

ATI RN Exit Exam

1. A client is at risk for developing deep vein thrombosis (DVT). Which of the following actions should the nurse take?

Correct answer: C

Rationale: The correct action the nurse should take for a client at risk for developing DVT is to apply sequential compression devices to the client's legs. This intervention helps prevent venous stasis by promoting circulation and reducing the risk of DVT. Encouraging the client to remain on bed rest (Choice A) can actually increase the risk of DVT due to immobility. Massaging the client's legs every 4 hours (Choice B) can dislodge blood clots and is contraindicated in DVT prevention. While administering anticoagulants as prescribed (Choice D) is a treatment for DVT, it is not a preventive measure for a client at risk.

2. A nurse is providing teaching to parents of a newborn about genetic screening. Which of the following statements should the nurse include in the teaching?

Correct answer: D

Rationale: The correct answer is D because avoiding public announcements about the baby's birth is crucial to reduce the risk of newborn abduction. Public announcements can attract unwanted attention and potentially jeopardize the safety of the newborn. Choices A, B, and C are incorrect. Choice A is incorrect because the baby's identification band should be kept on at all times for security purposes. Choice B is incorrect because leaving the baby unattended in the room can pose risks. Choice C is incorrect because identification bands are usually applied immediately after birth, not after the first bath.

3. A nurse is caring for a client who is postoperative following a total knee arthroplasty. Which of the following actions should the nurse take?

Correct answer: B

Rationale: Keeping the client's legs elevated is the appropriate action to prevent venous thromboembolism following a total knee arthroplasty. Elevating the legs helps promote circulation and reduce the risk of blood clots. Placing a pillow under the client's knees may provide comfort but does not address the specific postoperative complication. Flexing the client's knee every 2 hours may be contraindicated as excessive movement can disrupt the surgical site. Applying heat to the operative knee is not recommended immediately postoperatively as it can increase swelling and discomfort.

4. A client is experiencing a seizure. Which of the following interventions should the nurse implement?

Correct answer: B

Rationale: During a seizure, it is essential to loosen tight clothing around the client to prevent injury and promote adequate ventilation. Placing any objects, like a tongue depressor, in the client's mouth can lead to airway obstruction or injury. Restraining the client's arms and legs can exacerbate the situation by increasing muscle rigidity and potentially causing injury. Administering oxygen via a non-rebreather mask is not typically indicated during a seizure unless respiratory distress is present.

5. A client who has a new prescription for prednisone is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B because prednisone is usually prescribed for long-term use. Stopping it abruptly can lead to adrenal insufficiency. Choice A is incorrect because prednisone should be taken with food to prevent stomach upset. Choice C is incorrect as prednisone is typically tapered off gradually to avoid adverse effects. Choice D is incorrect as there is no specific requirement to take prednisone with a high-protein snack.

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