a nurse is caring for a client who is at risk for developing deep vein thrombosis dvt which of the following actions should the nurse implement
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Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam

1. A nurse is caring for a client who is at risk for developing deep vein thrombosis (DVT). Which of the following actions should the nurse implement?

Correct answer: C

Rationale: The correct action the nurse should implement is to apply sequential compression devices to the client's legs. This intervention helps prevent venous stasis and reduce the risk of deep vein thrombosis (DVT). Massaging the client's legs may dislodge a clot and is contraindicated in this situation (choice A). Encouraging bed rest may increase the risk of DVT due to prolonged immobility (choice B). While administering anticoagulants is a common treatment for DVT, in this case, the question is about preventive measures, and using sequential compression devices is a non-pharmacological approach.

2. A client with chronic kidney disease is being taught by a nurse about managing protein intake. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is B: 'You should limit your intake of high-protein foods.' Clients with chronic kidney disease should restrict their intake of high-protein foods to lessen the workload on the kidneys and prevent further kidney damage. Option A is incorrect as increasing intake of high-protein foods can exacerbate the condition. Option C is incorrect as avoiding all protein sources is not advisable, as some proteins are essential for overall health. Option D is incorrect as increasing the intake of animal protein can put more strain on the kidneys due to the metabolites produced during protein breakdown.

3. A client who is at 10 weeks of gestation and experiencing nausea and vomiting is receiving teaching from a nurse. Which of the following statements should the nurse include?

Correct answer: A

Rationale: The correct answer is A: 'You should eat crackers before getting out of bed.' Eating crackers before getting out of bed can help reduce nausea and vomiting during pregnancy. This recommendation helps in stabilizing blood sugar levels before fully waking up. Choice B is incorrect because ginger ale may exacerbate nausea due to its carbonation. Choice C is incorrect as lying down after eating can worsen symptoms of nausea. Choice D is incorrect as avoiding eating between meals can lead to low blood sugar levels, worsening nausea and vomiting.

4. A client is 2 hours postoperative following a total knee arthroplasty. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: A pain level of 8 is high and may indicate inadequate pain control or complications following surgery. Monitoring and managing pain is crucial postoperatively to ensure patient comfort and prevent complications. A heart rate of 88/min, capillary refill of 2 seconds, and a temperature of 37.8°C (100°F) are within normal ranges and do not typically require immediate reporting unless in the context of other concerning signs or symptoms.

5. A client is prescribed albuterol. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is B. Albuterol can cause tremors as a common side effect. Instructing the client about this potential side effect is crucial for their awareness and preparedness. Choices A, C, and D are incorrect because taking albuterol before meals, limiting caffeine intake, or taking it at bedtime are not specific instructions related to managing the side effects of albuterol like tremors.

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