a nurse is caring for a client who has a new diagnosis of deep vein thrombosis dvt which of the following actions should the nurse take
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Nursing Elites

ATI RN

ATI Exit Exam RN

1. A patient is diagnosed with deep vein thrombosis (DVT). Which of the following actions should the nurse take?

Correct answer: D

Rationale: Elevating the affected extremity is crucial in managing deep vein thrombosis (DVT) as it helps reduce swelling and promotes venous return, thereby preventing further complications such as pulmonary embolism. Massaging the affected extremity can dislodge a clot and lead to serious consequences. While ambulation is important, in DVT, early ambulation without elevation can potentially dislodge the clot. Warm compresses can increase blood flow to the area and worsen the condition by promoting clot dislodgement.

2. Which medication is commonly prescribed for a patient with hypertension?

Correct answer: A

Rationale: The correct answer is Lisinopril. Lisinopril is an ACE inhibitor commonly prescribed to patients with hypertension to manage their blood pressure. Metformin is used to treat type 2 diabetes, not hypertension (choice B). Atorvastatin is a statin used to lower cholesterol levels, not primarily prescribed for hypertension (choice C). Aspirin is used for its antiplatelet effects and in preventing cardiovascular events, but it is not a first-line treatment for hypertension (choice D). Therefore, Lisinopril is the most suitable choice for a patient with hypertension.

3. A client expresses fear of surgery. Which response should the nurse make?

Correct answer: D

Rationale: When a client expresses fear of surgery, it is essential for the nurse to acknowledge their feelings and ask open-ended questions. This response shows empathy, validates the client's emotions, and encourages them to express their concerns further. Explaining the risks of the surgery in detail (Choice A) may increase the client's anxiety. Simply stating that many clients feel anxious before surgery (Choice B) does not address the client's specific fears. While reassuring the client about the surgical team's experience (Choice C) is important, it may not directly alleviate the client's fear.

4. A healthcare provider is providing discharge instructions to a client with type 2 diabetes mellitus. Which resource should the healthcare provider provide?

Correct answer: D

Rationale: Food exchange lists from the American Diabetes Association are a valuable resource for structured meal planning in individuals with diabetes. These lists categorize foods based on macronutrient content and help individuals plan balanced meals to manage blood sugar levels effectively. Personal blogs may not always provide accurate and evidence-based information. Food label recommendations from the Institute of Medicine are important but may not be as specific to meal planning for diabetes. Diabetes medication information is crucial but not the primary focus when providing dietary instructions.

5. A client with a history of depression and experiencing a situational crisis is being assessed by a nurse. What action should the nurse take first?

Correct answer: A

Rationale: When a client with a history of depression is experiencing a situational crisis, the first action the nurse should take is to notify the client's support system. This is crucial as the client may require immediate assistance and support. While helping the client identify personal strengths and confirming the client's perception of the event are important aspects of the assessment and intervention process, notifying the support system takes priority in ensuring the client's safety and well-being. Teaching relaxation techniques may be beneficial but addressing the client's immediate crisis through support system notification is the most appropriate initial action.

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