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. How should a healthcare professional assess a patient for dehydration?

Correct answer: A

Rationale: Checking for skin turgor is a reliable method to assess dehydration in patients. Skin turgor refers to the skin's elasticity and hydration status. When a healthcare professional gently pinches the skin on the back of the patient's hand or forearm, dehydration is indicated by the skin not snapping back immediately. Monitoring blood pressure (choice B) is important but is more indicative of cardiovascular status rather than dehydration specifically. Checking for dry mucous membranes (choice C) can be a sign of dehydration, but skin turgor is a more direct assessment. Monitoring urine output (choice D) is also essential but may not provide immediate feedback on hydration status as skin turgor does.

3. What is the best way to assess a patient's respiratory function after surgery?

Correct answer: A

Rationale: The correct answer is to check oxygen saturation. This is because checking oxygen saturation provides a direct measure of how well the patient is oxygenating post-surgery. It helps healthcare providers assess if the patient is receiving enough oxygen to meet their body's needs. Auscultating lung sounds (choice B) is important to assess respiratory function but may not provide an immediate indication of oxygenation status. Checking for abnormal breath sounds (choice C) is relevant but does not directly assess oxygenation levels. Checking skin color (choice D) can provide some information about oxygenation, but it is not as precise or direct as measuring oxygen saturation.

4. A nurse is providing dietary teaching to a client who is at risk for osteoporosis. Which of the following foods should the nurse recommend?

Correct answer: C

Rationale: Cheddar cheese is an excellent source of calcium, which is essential for bone health. Calcium helps strengthen bones and reduces the risk of osteoporosis. Broccoli (choice A) is also a good source of calcium but not as high as cheddar cheese. Bananas (choice B) and whole wheat bread (choice D) do not provide significant amounts of calcium and are not as effective in preventing osteoporosis as cheddar cheese.

5. A nurse is providing teaching to parents of a newborn about genetic screening. Which of the following statements should the nurse include in the teaching?

Correct answer: D

Rationale: The correct answer is D because avoiding public announcements about the baby's birth is crucial to reduce the risk of newborn abduction. Public announcements can attract unwanted attention and potentially jeopardize the safety of the newborn. Choices A, B, and C are incorrect. Choice A is incorrect because the baby's identification band should be kept on at all times for security purposes. Choice B is incorrect because leaving the baby unattended in the room can pose risks. Choice C is incorrect because identification bands are usually applied immediately after birth, not after the first bath.

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