a nurse is caring for a client with 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 Form B

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

Correct answer: D

Rationale: The correct answer is to elevate the affected leg while in bed. Elevating the leg helps reduce swelling and promotes venous return, aiding in the management of DVT. Positioning the affected leg below the heart can worsen the condition by increasing the risk of clot dislodgment. Massaging the affected extremity can also dislodge the clot and should be avoided. Cold compresses are not recommended as they can cause vasoconstriction, potentially worsening the condition.

2. A nurse is assessing a client with suspected myocardial infarction. Which finding supports this diagnosis?

Correct answer: A

Rationale: The correct answer is A. Pain radiating to the left arm is a classic symptom of myocardial infarction, commonly known as a heart attack. This occurs due to the referred pain pathways shared by the heart and the left arm. Choices B, C, and D are incorrect. Pain relieved by rest (choice B) is more indicative of musculoskeletal pain rather than cardiac-related pain. Pain worsening with deep breathing (choice C) is often seen in conditions like pleurisy or pulmonary embolism, not myocardial infarction. Pain relieved by antacids (choice D) suggests gastrointestinal issues like heartburn or acid reflux, not cardiac-related pain.

3. A nurse is assessing a client who is receiving chemotherapy and has stomatitis. Which of the following findings should the nurse expect?

Correct answer: D

Rationale: The correct answer is D: Red, open sores in the mouth. Stomatitis, a common side effect of chemotherapy, presents with red, open sores in the mouth, which can be painful and increase the risk of infection. Choices A, B, and C are incorrect because stomatitis typically does not manifest as dry, cracked lips, bleeding gums, or foul-smelling breath.

4. A client has been prescribed raloxiphene. As the nurse, you know that raloxiphene is used to treat:

Correct answer: C

Rationale: Raloxiphene (Evista) is a selective estrogen receptor modulator (SERM) used primarily to prevent and treat osteoporosis in postmenopausal women. It helps to maintain bone density and reduce the risk of fractures by mimicking the effects of estrogen on bone tissue. It is not indicated for the treatment of migraines, hypertension, or heart disease. Therefore, the correct answer is osteoporosis (Choice C). Choices A, B, and D are incorrect as raloxiphene is not used to treat migraines, hypertension, or heart disease.

5. A healthcare provider is reviewing the medical records of a group of older adults (OA). The provider should identify that which of the following is a risk factor that places OA at an increased risk for developing infections?

Correct answer: C

Rationale: The correct answer is C: 'Lowered immune system function.' As individuals age, their immune system tends to weaken, making them more susceptible to infections. Choices A, B, and D are incorrect because improved circulation and increased immune function would typically reduce the risk of infections, while dehydration can impact overall health but is not directly related to immune system function in the context of infection risk.

Similar Questions

A nurse is preparing to administer a dose of enoxaparin. Which of the following actions should the nurse take?
A client is receiving vancomycin. Which of the following should the nurse monitor?
A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. The client reports heavy bleeding and passing large clots. What is the priority action for the nurse to take?
When resolving a conflict, which statement made by the charge nurse is an example of smoothing?
A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as part of which type of immunity?

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