a nurse is caring for a client who has a pulmonary embolism which of the following interventions should the nurse include in the plan of care

ATI RN

ATI Exit Exam 2024

1. A client with a pulmonary embolism is being cared for by a nurse. Which of the following interventions should the nurse include in the plan of care?

A. Encourage the client to ambulate frequently.
B. Place the client in a prone position.
C. Administer anticoagulants as prescribed.
D. Initiate seizure precautions.

Correct answer: C

Rationale: Administering anticoagulants as prescribed is a crucial intervention for clients with pulmonary embolism to prevent further clot formation. Encouraging the client to ambulate frequently may dislodge the clot and lead to worsening symptoms. Placing the client in a prone position can compromise respiratory function. Initiating seizure precautions is not directly related to the management of pulmonary embolism.

2. What is the best intervention for a patient with constipation?

A. Administer a stool softener
B. Encourage fluid intake
C. Provide a high-fiber diet
D. Administer a laxative

Correct answer: B

Rationale: Encouraging fluid intake is the best intervention for a patient with constipation. Fluids help soften stools, making them easier to pass. While stool softeners and laxatives can also help with constipation, they are more of a short-term solution and may not address the root cause. A high-fiber diet is beneficial for preventing constipation in the long run, but in the immediate situation of constipation, fluid intake is key.

3. What is the best initial action when a patient presents with confusion?

A. Administer IV fluids
B. Perform a neurological assessment
C. Administer electrolytes
D. Prepare for a CT scan

Correct answer: B

Rationale: When a patient presents with confusion, the best initial action is to perform a neurological assessment. This assessment helps in identifying potential causes of confusion such as neurological issues, infections, metabolic abnormalities, or medication side effects. Administering IV fluids (Choice A) may be necessary based on assessment findings, but it is not the first step. Administering electrolytes (Choice C) would also depend on the assessment results. Preparing for a CT scan (Choice D) may be indicated later in the diagnostic process but is not the initial action when a patient presents with confusion.

4. A nurse is reviewing the laboratory results of a client who is at 36 weeks of gestation. The nurse should report which of the following laboratory results to the provider?

A. Hemoglobin 11.2 g/dL
B. Platelet count 148,000/mm3
C. Leukocyte count 9,000/mm3
D. Blood glucose 80 mg/dL

Correct answer: A

Rationale: A hemoglobin level of 11.2 g/dL is below the normal range for a client who is 36 weeks gestation and should be reported to the provider.

5. A healthcare provider is reviewing laboratory results for a client who is receiving heparin therapy. Which of the following results indicates that the medication is effective?

A. Platelets 250,000/mm³
B. aPTT 60 seconds
C. Hemoglobin 15 g/dL
D. INR 1.5

Correct answer: B

Rationale: An aPTT of 60 seconds indicates that the client is receiving an effective dose of heparin. The activated partial thromboplastin time (aPTT) measures the time it takes for blood to clot and is used to monitor heparin therapy. A therapeutic range for aPTT during heparin therapy is usually 1.5 to 2 times the control value, which is around 25-35 seconds. Platelets, hemoglobin, and INR values are not direct indicators of the effectiveness of heparin therapy.