a nurse is caring for a client with deep vein thrombosis dvt who is receiving heparin therapy what is the priority assessment
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam

1. A client with deep vein thrombosis (DVT) is receiving heparin therapy. What is the priority assessment for the nurse?

Correct answer: C

Rationale: Assessing for signs of bleeding is the priority when caring for a client with deep vein thrombosis (DVT) receiving heparin therapy. Heparin therapy increases the risk of bleeding complications, so monitoring for signs of bleeding is crucial to ensure patient safety and timely intervention if needed.

2. A patient is assessing a client who has just been admitted to the emergency department. The client is having difficulty breathing and is using accessory muscles. What action by the nurse is best?

Correct answer: D

Rationale: Placing the client in a high Fowler's position is the best action in this situation as it helps to maximize lung expansion, improve breathing, and decrease the work of breathing. This position allows for better chest expansion, improving oxygenation and ventilation for the client in respiratory distress.

3. A healthcare professional assesses a client's respiratory status. Which information is of highest priority for the healthcare professional to obtain?

Correct answer: D

Rationale: Obtaining information about a client's occupation and hobbies is crucial when assessing respiratory status as many respiratory problems can result from chronic exposure to inhalation irritants related to these activities. Understanding the client's potential exposure can help the healthcare professional identify risk factors and provide appropriate interventions to promote respiratory health.

4. A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

Correct answer: D

Rationale: Gastroenteritis can lead to fluid loss through vomiting and diarrhea, especially when accompanied by fever. Fever can increase insensible water loss through sweating as well. Both vomiting and diarrhea can significantly contribute to fluid volume deficit, making the client with gastroenteritis and fever at higher risk compared to the other clients described in the options.

5. The trauma unit nurse has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

Correct answer: A

Rationale: In a client with multiple injuries following a motor vehicle crash, the priority is to assess for any compromised airway or breathing. Evaluating chest expansion helps the nurse determine if the client is having any difficulty breathing, which is essential for immediate intervention to maintain adequate oxygenation. Checking pupillary response, assessing capillary refill, and checking the client's orientation to place and time are important assessments but are of lower priority compared to ensuring the client's airway and breathing are intact.

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