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. When teaching a patient with a new prescription for brimonidine to treat open-angle glaucoma, what indicates an understanding of the instructions?

Correct answer: C

Rationale: The correct answer is C. When using brimonidine to treat open-angle glaucoma, patients may experience temporary irritation in the eyes. Choice A is incorrect because vision improvement from brimonidine is not immediate. Choice B is incorrect as brimonidine should be used as prescribed, not just when eyes are irritated. Choice D is important but does not directly indicate an understanding of the medication's use.

3. A healthcare provider is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins that promote wound healing should the healthcare provider include in the teaching? (SATA)

Correct answer: B

Rationale: The correct answer is Vitamin C. Vitamin C is essential for wound healing due to its role in collagen production. Collagen is crucial for wound repair and the formation of new tissue. Vitamin B12 is important for nerve function and DNA synthesis but is not directly related to wound healing. Vitamin K is essential for blood clotting and bone health but does not directly promote wound healing. Vitamin D plays a role in bone health and immune function but is not a primary vitamin involved in wound healing.

4. During a home visit with an older adult client, a nurse should address which of the following observations to promote a safe environment?

Correct answer: C

Rationale: The correct answer is C: Low chairs without armrests. This observation should be addressed by the nurse to promote a safe environment for the older adult client. Low chairs without armrests increase the risk of falls as they can be challenging for older adults to sit down on or get up from. Addressing this issue can help prevent falls and promote safety. Choices A, B, and D are not as crucial for promoting a safe environment compared to the risk posed by low chairs without armrests.

5. A nurse is receiving change-of-shift report on a group of clients. Which of the following clients should the nurse assess first?

Correct answer: D

Rationale: The correct answer is D because a client with a fractured femur and sudden chest pain may be experiencing a pulmonary embolism, which requires immediate assessment. Choice A is incorrect because although severe pain is present, it is more indicative of musculoskeletal issues related to urolithiasis rather than a life-threatening condition. Choice B, related to acute cholecystitis, is less urgent than choice D as the pain radiating to the right shoulder is a common symptom but does not indicate an immediate life-threatening situation. Choice C, regarding a client post-total knee arthroplasty with a pain level of 8, is important but not as urgent as a potential pulmonary embolism in choice D.

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