ATI RN

1. A nurse is caring for a client who is at risk for developing deep vein thrombosis (DVT). Which of the following actions should the nurse implement?

• A. Massage the client's legs every 2 hours.
• B. Encourage the client to remain on bed rest.
• C. Apply sequential compression devices to the client's legs.
• D. Administer anticoagulants as prescribed.

Correct Answer: C

Rationale: The correct action the nurse should implement is to apply sequential compression devices to the client's legs. This intervention helps prevent venous stasis and reduce the risk of deep vein thrombosis (DVT). Massaging the client's legs may dislodge a clot and is contraindicated in this situation (choice A). Encouraging bed rest may increase the risk of DVT due to prolonged immobility (choice B). While administering anticoagulants is a common treatment for DVT, in this case, the question is about preventive measures, and using sequential compression devices is a non-pharmacological approach.

2. How should a healthcare provider respond to a patient with a history of hypertension who is non-compliant with medication?

• A. Encourage compliance through education
• B. Contact the healthcare provider
• C. Document the refusal
• D. Explore alternative treatment options

Correct Answer: A

Rationale: Encouraging compliance through education is crucial in helping patients understand the importance of consistent medication use. By providing education, the patient can make informed decisions about their health and better manage their condition. Contacting the healthcare provider (choice B) may be necessary in some cases, but the initial approach should focus on patient education. Documenting the refusal (choice C) is important for legal and medical records but does not address the root cause of non-compliance. Exploring alternative treatment options (choice D) should come after efforts to educate and encourage compliance with the current medication regimen.

3. A healthcare professional is assessing a client who has chronic kidney disease. Which of the following findings is an indication for hemodialysis?

• A. BUN 16 mg/dL
• B. Serum magnesium 1.8 mg/dL
• C. Serum phosphorus 4.0 mg/dL
• D. Glomerular filtration rate of 14 mL/min

Correct Answer: D

Rationale: A glomerular filtration rate of 14 mL/min indicates severe kidney impairment and the need for hemodialysis. The other choices, such as BUN 16 mg/dL, serum magnesium 1.8 mg/dL, and serum phosphorus 4.0 mg/dL, are within normal ranges and do not directly indicate the need for hemodialysis in chronic kidney disease.

4. How should a healthcare professional assess for infection in a patient post-surgery?

• A. Check the surgical site
• B. Check for fever
• C. Check for abnormal breath sounds
• D. Check the patient's skin color

Correct Answer: A

Rationale: When assessing for infection in a patient post-surgery, checking the surgical site is crucial. Changes in the appearance of the surgical site, such as redness, swelling, warmth, or drainage, can indicate an infection. While checking for fever (Choice B) is also important as it can be a sign of infection, it is a more general symptom and may not always be present. Checking for abnormal breath sounds (Choice C) and skin color (Choice D) are not typically direct indicators of infection in a post-surgery patient.

5. How should a healthcare provider manage a patient with chronic heart failure?

• A. Monitor daily weight
• B. Provide fluid restriction
• C. Administer diuretics
• D. Monitor intake and output

Correct Answer: A

Rationale: Corrected Rationale: Daily weight monitoring is crucial in managing patients with chronic heart failure as it helps assess fluid balance. Monitoring daily weight allows healthcare providers to detect any sudden weight gain, which could indicate fluid retention and worsening heart failure. This intervention helps in adjusting treatment plans promptly. Providing fluid restriction (Choice B) can be a part of managing heart failure but is not the primary intervention mentioned in the question. Administering diuretics (Choice C) is a treatment modality for heart failure but does not encompass the comprehensive approach to patient management. Monitoring intake and output (Choice D) is important but does not specifically address the direct assessment of fluid status as daily weight monitoring does.