ATI RN
ATI RN Exit Exam Test Bank
1. What is the best way to manage a patient with suspected deep vein thrombosis (DVT)?
- A. Administer anticoagulants
- B. Apply compression stockings
- C. Encourage ambulation
- D. Monitor oxygen saturation
Correct answer: A
Rationale: The correct answer is A: Administer anticoagulants. Administering anticoagulants is crucial in managing patients with suspected DVT as it helps prevent further clot formation and reduces the risk of complications like pulmonary embolism. Choice B, applying compression stockings, is more focused on preventing DVT in high-risk patients rather than managing an established case. Encouraging ambulation, choice C, is beneficial in the prevention of DVT but is not the primary management for suspected cases. Monitoring oxygen saturation, choice D, is important in overall patient care but is not the primary intervention for suspected DVT.
2. What is the appropriate nursing action for a patient experiencing an acute allergic reaction?
- A. Administer antihistamines
- B. Administer corticosteroids
- C. Administer oxygen
- D. Administer bronchodilators
Correct answer: A
Rationale: The appropriate nursing action for a patient experiencing an acute allergic reaction is to administer antihistamines. Antihistamines work by blocking the action of histamine, a chemical released during an allergic reaction, and can help relieve symptoms such as itching, swelling, and hives. Corticosteroids are used for severe allergic reactions not responding to antihistamines, as they have anti-inflammatory properties. Oxygen is administered in cases of respiratory distress, while bronchodilators are used for bronchospasms. However, the first-line intervention for an acute allergic reaction is antihistamines.
3. A client has deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?
- A. Apply cold compresses to the affected extremity.
- B. Massage the affected extremity every 2 hours.
- C. Elevate the affected extremity above the level of the heart.
- D. Keep the affected extremity dependent when sitting.
Correct answer: C
Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to elevate the affected extremity above the level of the heart. This position promotes venous return, reduces swelling, and helps prevent complications such as pulmonary embolism. Applying cold compresses (choice A) can vasoconstrict blood vessels, potentially worsening the condition. Massaging the affected extremity (choice B) can dislodge the clot and lead to serious complications. Keeping the affected extremity dependent when sitting (choice D) can hinder venous return and exacerbate the DVT.
4. A nurse is caring for a client who is at risk for developing deep vein thrombosis (DVT). Which of the following interventions should the nurse implement?
- A. Massage the client's legs every 4 hours.
- B. Administer prophylactic antibiotics.
- C. Apply sequential compression devices to the client's legs.
- D. Encourage the client to remain on bed rest.
Correct answer: C
Rationale: Applying sequential compression devices is the appropriate intervention for a client at risk for developing deep vein thrombosis (DVT). This intervention helps prevent venous stasis by promoting circulation in the lower extremities, reducing the risk of DVT. Massaging the client's legs every 4 hours is contraindicated as it can dislodge a blood clot and increase the risk of embolism. Administering prophylactic antibiotics is not indicated for preventing DVT. Encouraging the client to remain on bed rest can contribute to venous stasis and increase the risk of developing DVT.
5. A nurse is caring for a client who is in labor and is receiving electronic fetal monitoring. The nurse notes early decelerations. Which of the following should the nurse expect?
- A. Fetal hypoxia
- B. Head compression
- C. Placenta previa
- D. Umbilical cord prolapse
Correct answer: B
Rationale: In the scenario of early decelerations noted during labor with electronic fetal monitoring, the nurse should expect head compression. Early decelerations are a normal response to fetal head compression during contractions and are not indicative of fetal distress. Choice A, fetal hypoxia, is incorrect as early decelerations are not associated with fetal oxygen deprivation. Choices C and D, placenta previa and umbilical cord prolapse, are unrelated to the scenario described and do not cause early decelerations.
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