a nurse is caring for a client with deep vein thrombosis dvt which action should the nurse take
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment Form A

1. A nurse is caring for a client with deep vein thrombosis (DVT). Which action should the nurse take?

Correct answer: D

Rationale: Withholding heparin IV infusion is the priority if there is a risk of complications such as bleeding, which must be evaluated before continuing treatment.

2. A client with a permanent spinal cord injury is scheduled for discharge. Which of the following client statements indicates that the client is coping effectively?

Correct answer: A

Rationale: Choice A is the correct answer. This statement demonstrates effective coping as the client is showing acceptance of their disability and planning for the future with realistic goals. Choice B reflects denial of the permanent disability by stating that they will only be in a wheelchair temporarily. Choice C shows distress and a lack of acceptance by questioning why the injury happened and why they are not improving. Choice D indicates feelings of hopelessness and being a burden, which are not signs of effective coping.

3. A nurse is caring for an infant who has a prescription for continuous pulse oximetry. Which of the following is an appropriate action for the nurse to take?

Correct answer: B

Rationale: The correct answer is to move the probe site every 3 hours. This action helps prevent skin breakdown and ensures more accurate monitoring of oxygen saturation. Placing the infant under a radiant warmer (choice A) is unnecessary and not related to pulse oximetry. Heating the skin before placing the probe (choice C) can lead to burns and is not recommended. Placing the sensor on the index finger (choice D) is not appropriate for continuous monitoring in infants.

4. A nurse is caring for a client with congestive heart failure. Which of the following prescriptions should the nurse anticipate?

Correct answer: C

Rationale: Enalapril, an ACE inhibitor, is commonly prescribed to manage hypertension and heart failure. It helps reduce the workload on the heart and prevent fluid retention. Options A, B, and D are incorrect. Option A focuses on a respiratory rate, which is not specific to heart failure management. Option B suggests administering a large IV bolus of fluid, which can worsen heart failure by increasing fluid volume. Option D addresses the pulse rate, which is not a typical parameter to monitor for heart failure specifically.

5. A nurse is caring for a client who has end-stage osteoporosis and is reporting severe pain. The client’s respiratory rate is 14 per minute. Which of the following medications should the nurse prioritize administering?

Correct answer: B

Rationale: Hydromorphone, an opioid, is the most appropriate option for managing severe pain in this context. Opioids provide fast-acting relief for acute pain associated with advanced osteoporosis. Promethazine (Choice A) is an antihistamine and not indicated for pain relief. Ketorolac (Choice C) is a nonsteroidal anti-inflammatory drug (NSAID) that may increase the risk of bleeding and is not recommended for severe pain management. Amitriptyline (Choice D) is a tricyclic antidepressant that is not the first-line treatment for severe acute pain.

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