what is the nurses priority when assessing a patient for possible deep vein thrombosis dvt
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN

1. What is the priority when assessing a patient for possible deep vein thrombosis (DVT)?

Correct answer: B

Rationale: The correct answer is to measure the calf circumference of both legs when assessing a patient for possible DVT. An increase in calf circumference in one leg can indicate the presence of a DVT. Option A is incorrect because dorsiflexing the foot and checking for pain are not primary assessments for DVT. Option C is incorrect as redness of the skin may not always be present in cases of DVT. Option D is incorrect as performing a Doppler ultrasound scan is usually done after clinical assessment and to confirm the diagnosis, not as the initial priority assessment.

2. A healthcare professional is assessing a patient with pneumonia. Which finding is most concerning?

Correct answer: D

Rationale: Crackles heard in the lung bases are most concerning in a patient with pneumonia as they suggest fluid accumulation in the lungs, indicating possible severe infection or respiratory distress. Prompt intervention is required to prevent further complications.\n\nChoice A, fever of 101°F, is common in infections like pneumonia but may not be as immediately concerning as crackles indicating fluid in the lungs.\n\nChoice B, a blood pressure of 140/90 mmHg, is within normal limits and not directly indicative of pneumonia severity.\n\nChoice C, a heart rate of 95 beats per minute, is slightly elevated but not as critical as crackles suggesting fluid in the lungs.

3. The surgical mask the perioperative nurse is wearing becomes moist. Which action will the perioperative nurse take next?

Correct answer: C

Rationale: When a surgical mask becomes moist, it loses its effectiveness as a barrier against microorganisms. Therefore, the perioperative nurse should apply a new mask. Choice A is incorrect because a moist mask should not be continued to be worn even if the nurse is comfortable. Choice B is not the best course of action as the mask should be changed immediately when it becomes moist. Choice D is also incorrect as waiting for the mask to air-dry is not recommended due to the loss of barrier effectiveness.

4. While reviewing notes from a previous shift, a nurse finds incomplete documentation. What is the most appropriate action?

Correct answer: B

Rationale: The most appropriate action when finding incomplete documentation is to notify the nurse manager of the issue. This ensures that accurate records are maintained and the situation can be addressed properly. Completing the missing documentation on behalf of someone else may lead to inaccuracies, asking the nurse to complete it may not guarantee timely correction, and confronting the nurse could create a confrontational situation that is not conducive to effective teamwork.

5. A patient has a new prescription for allopurinol to treat gout. What should the nurse include in the teaching?

Correct answer: C

Rationale: Correct answer: Increasing fluid intake is essential when taking allopurinol to prevent kidney stones and aid in uric acid excretion. This helps reduce the risk of developing complications associated with gout. Decreasing protein intake (Choice A) is not directly related to allopurinol therapy. Limiting salt intake (Choice B) and alcohol consumption (Choice D) are important for overall health but are not specific recommendations when taking allopurinol for gout.

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