a nurse is caring for a client with deep vein thrombosis dvt which action should the nurse take
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment Form A

1. A nurse is caring for a client with deep vein thrombosis (DVT). Which action should the nurse take?

Correct answer: D

Rationale: Withholding heparin IV infusion is the priority if there is a risk of complications such as bleeding, which must be evaluated before continuing treatment.

2. A nurse is providing discharge teaching to a client with heart failure and a prescription for furosemide 20 mg PO twice daily. Which of the following instructions should the nurse include in the teaching?

Correct answer: B

Rationale: The correct answer is B: "Increase intake of high-potassium foods." Furosemide is a loop diuretic that can lead to hypokalemia, a condition characterized by low potassium levels. To prevent this adverse effect, the client should increase their intake of high-potassium foods. Choice A is incorrect because furosemide typically leads to decreased blood pressure, not increased. Choice C is incorrect because furosemide is used to reduce swelling, not increase it. Choice D is incorrect because the second dose of furosemide should be taken in the morning to prevent nocturia.

3. A nurse is caring for a client who is in active labor. The nurse notes early decelerations in the FHR on the fetal monitor tracing. The nurse should identify that which of the following conditions causes early decelerations in the FHR?

Correct answer: D

Rationale: Early decelerations are caused by head compression during contractions, which is a normal response as the fetal head is being compressed during uterine contractions. This usually indicates that the fetus is descending into the birth canal. Choices A, B, and C are incorrect. Fetal hypoxemia, cord compression, and uteroplacental insufficiency typically present with variable or late decelerations on the fetal heart rate tracing, not early decelerations.

4. A client newly diagnosed with nephrotic syndrome is being taught by a nurse. Which statement indicates that the client understands the teaching?

Correct answer: A

Rationale: The correct answer is A: “I can expect swelling in my hands and on my face.” Nephrotic syndrome leads to increased permeability of the glomeruli, resulting in edema, especially in the face and dependent areas. Choice B is incorrect because nephrotic syndrome leads to protein loss in the urine, not an increase in blood protein levels. Choice C is incorrect as stomach pain and gas are not typical symptoms of nephrotic syndrome. Choice D is unrelated to the teaching about nephrotic syndrome and gum bleeding.

5. A healthcare professional is teaching a client about reducing the risk of urinary tract infections (UTIs). Which factor increases the risk of UTI?

Correct answer: C

Rationale: Using perfumed toilet paper can irritate the urinary tract and increase the risk of UTI, so it should be avoided. Wearing underwear with a cotton crotch (Choice A) is a preventive measure as cotton allows for better air circulation and reduces moisture, lowering the risk of UTIs. Wiping from front to back (Choice B) helps prevent the introduction of bacteria from the anal region to the urinary tract. Urinating after intercourse (Choice D) can help flush out bacteria introduced during sexual activity, thereby reducing the risk of UTIs.

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