a nurse is planning care for a client who has a new diagnosis of 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 B

1. A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which action should the nurse take?

Correct answer: B

Rationale: Elevating the leg promotes venous return and reduces swelling, which is crucial for clients with DVT. Massaging the affected extremity can dislodge the clot and worsen the condition. Applying cold packs can cause vasoconstriction, potentially increasing the risk of clot formation. Keeping the leg dependent can impede circulation and increase the risk of clot migration.

2. A charge nurse is discussing the use of applying ice to a client’s injured knee with a newly licensed nurse. Which of the following is a benefit of this treatment?

Correct answer: C

Rationale: The correct answer is C: Decreased capillary permeability. Ice application helps decrease capillary permeability, which in turn reduces swelling and inflammation at the injury site. This vasoconstriction effect helps to limit the extent of the injury. Choices A, B, and D are incorrect. Applying ice locally does not produce a systemic analgesic effect but rather a localized numbing effect. It does not increase metabolism but rather slows down metabolic processes in the affected area. Additionally, ice application causes vasoconstriction, not vasodilation.

3. A nurse is teaching a client about the use of aspirin. Which of the following should be included?

Correct answer: C

Rationale: The correct answer is C: 'Monitor for signs of bleeding.' Aspirin is known to increase the risk of bleeding, so clients should be monitored for this potential side effect. Choice A is incorrect because aspirin is not typically associated with causing drowsiness. Choice B is not a specific consideration for aspirin use; it is not necessary to take it with food. Choice D is incorrect because aspirin is not considered safe during pregnancy and should be avoided, especially in the third trimester, as it may cause complications for the mother and the baby.

4. A nurse is reviewing a laboratory report for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?

Correct answer: A

Rationale: A BUN of 35 mg/dL indicates potential kidney impairment, which is a concern in preeclampsia due to compromised renal function. This finding warrants further evaluation by the provider. High BUN levels may suggest reduced kidney function, a common complication associated with preeclampsia. Hgb, Bilirubin, and Hct levels are within normal ranges and are not directly indicative of kidney impairment or preeclampsia in this scenario. Therefore, the nurse should report the elevated BUN level to the healthcare provider for prompt management and monitoring.

5. A client with osteoporosis is being taught by a nurse about dietary changes. Which of the following food choices should the nurse recommend to promote bone health?

Correct answer: C

Rationale: The correct answer is C: Fortified orange juice. Fortified orange juice is often supplemented with calcium and vitamin D, both of which are essential for bone health and the prevention of osteoporosis. Leafy green vegetables (choice A) are good for overall health but may not provide sufficient calcium for bone health. Red meat (choice B) is a source of protein but is not a primary source of calcium. Whole grains (choice D) are beneficial for fiber intake but do not contain significant amounts of calcium or vitamin D necessary for bone health.

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