a nurse is assessing a client who is receiving a continuous iv infusion of heparin which of the following findings should the nurse report to the prov

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment Form A

1. A nurse is assessing a client who is receiving a continuous IV infusion of heparin. Which of the following findings should the nurse report to the provider?

A. Report any urine output greater than 30 mL/hr.
B. Bruising on the arms and legs.
C. Positive Trousseau's sign.
D. Urine output of 60 mL/hr.

Correct answer: B

Rationale: The correct answer is B. Bruising on the arms and legs is a sign of bleeding, which is a serious complication of heparin therapy and should be reported immediately to the provider. Option A is incorrect as urine output greater than 30 mL/hr is a normal finding. Option C, positive Trousseau's sign, is associated with hypocalcemia, not heparin therapy. Option D, urine output of 60 mL/hr, is within the normal range and does not indicate a complication of heparin therapy.

2. Which question is essential during screening for alcohol use disorder?

A. What is your current employment status?
B. Have you experienced any blackouts or loss of consciousness?
C. Have you been sleeping well over the past month?
D. Do you have a family history of substance use?

Correct answer: B

Rationale: The essential question during screening for alcohol use disorder is asking about blackouts or loss of consciousness, which can be indicative of excessive drinking and related to alcohol use disorder. Choices A, C, and D are not as directly related to screening for alcohol use disorder. Employment status (Choice A) is not a primary question in alcohol use disorder screening. Sleep quality (Choice C) and family history of substance use (Choice D) may be relevant but are not as crucial as inquiring about blackouts or loss of consciousness.

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)

A. Vitamin B12
B. Vitamin C
C. Vitamin K
D. Vitamin D

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. A patient with a urinary tract infection (UTI) requires treatment. What is the most appropriate intervention?

A. Encourage the patient to increase fluid intake.
B. Administer antibiotics as prescribed.
C. Recommend the patient take over-the-counter pain relievers.
D. Encourage the patient to limit physical activity.

Correct answer: B

Rationale: The correct answer is to administer antibiotics as prescribed. Antibiotics are the primary treatment for urinary tract infections as they help eliminate the bacteria causing the infection. Encouraging the patient to increase fluid intake (Choice A) is a supportive measure to help flush out the bacteria but doesn't directly treat the infection. Over-the-counter pain relievers (Choice C) may help with discomfort but do not address the underlying infection. Limiting physical activity (Choice D) may be recommended for some conditions but is not the primary intervention for treating a UTI.

5. Which factor places a patient at the highest risk for infection?

A. A healthy immune system
B. Presence of chronic illness
C. Being well-nourished
D. Age over 65 years

Correct answer: B

Rationale: The presence of chronic illness is the factor that places a patient at the highest risk for infection. Chronic illness can compromise the immune system's ability to fight off infections effectively, making individuals more susceptible to getting sick. Option A, a healthy immune system, actually reduces the risk of infection. Option C, being well-nourished, can support overall health but does not directly correlate with infection risk. While age over 65 years is a risk factor for certain infections due to age-related immune system changes, chronic illness has a more significant impact on infection risk.