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

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ATI RN Exit Exam Test Bank

1. A nurse is caring for a client who is at risk for developing deep vein thrombosis (DVT). Which of the following interventions should the nurse implement?

Correct answer: C

Rationale: Applying sequential compression devices is the appropriate intervention for a client at risk for developing deep vein thrombosis (DVT). This intervention helps prevent venous stasis by promoting circulation in the lower extremities, reducing the risk of DVT. Massaging the client's legs every 4 hours is contraindicated as it can dislodge a blood clot and increase the risk of embolism. Administering prophylactic antibiotics is not indicated for preventing DVT. Encouraging the client to remain on bed rest can contribute to venous stasis and increase the risk of developing DVT.

2. A client reports that the medication appears different than what they take at home. Which of the following responses should the nurse take?

Correct answer: D

Rationale: Contacting the pharmacist is the most appropriate action to ensure the correct medication is being administered. This response addresses the client's concern directly and prioritizes patient safety. The other options do not directly address the issue of the medication discrepancy. Option A focuses on the healthcare provider's discussion, not the medication itself. Option B assumes that the current medication is correct without verification. Option C addresses the reason for the prescription but does not verify the medication's correctness.

3. A client who is 14 weeks of gestation reports swelling of the face. What should the nurse do next?

Correct answer: B

Rationale: The correct answer is to report this finding to the provider immediately. Swelling of the face in pregnancy can be a sign of preeclampsia, a serious condition characterized by high blood pressure and signs of damage to another organ system, often the kidneys. Prompt reporting and intervention are crucial to prevent complications for both the client and the fetus. Administering an analgesic (choice A) is not appropriate for this situation as it does not address the underlying cause of the swelling. Administering an antiemetic (choice C) is used to treat nausea and vomiting, which are not the primary concerns associated with facial swelling in this scenario. Monitoring the client's vital signs (choice D) is important but should be done after reporting the finding to the provider to guide further assessment and management.

4. A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client's contractions are occurring every 45 seconds with a nine-second duration, and the fetal heart rate is 170 to 180 beats per minute. Which of the following actions should the nurse take?

Correct answer: A

Rationale: In this scenario, the client is experiencing frequent contractions with a short duration and an elevated fetal heart rate, indicating potential fetal distress. Discontinuing the oxytocin infusion is crucial to prevent further complications and restore normal fetal parameters. Increasing or maintaining the oxytocin infusion could exacerbate the situation, leading to more distress for the fetus. Decreasing the oxytocin infusion may not be sufficient to address the current issue and could delay the improvement of fetal well-being.

5. A healthcare provider is reviewing the laboratory report of a client with a prescription for digoxin. Which result requires withholding the medication?

Correct answer: D

Rationale: The correct answer is D. A low potassium level (3.1 mEq/L) can increase the risk of digoxin toxicity. Hypokalemia can potentiate the effects of digoxin on the heart, leading to serious dysrhythmias. Choices A, B, and C are within normal ranges and do not indicate a need to withhold digoxin.

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