a nurse is caring for a client with deep vein thrombosis dvt who is receiving heparin therapy what is the priority assessment 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. The nurse is preparing a presentation on compensated, decompensated, and irreversible shock in children. What clinical manifestations related to decompensated shock should the nurse include? (Select all that apply.)

Correct answer: A

Rationale: Decompensated shock is characterized by signs such as oliguria, confusion, pale extremities, hypotension, and a thready pulse. These indicate that the body is no longer able to maintain adequate circulation to vital organs.

3. What is the primary action when a healthcare provider discovers a patient has fallen?

Correct answer: A

Rationale: When a healthcare provider discovers a patient has fallen, the primary action should be to assess the patient for injuries. This is crucial to determine the extent of harm and if immediate treatment is necessary. Calling for help is important, but assessing the patient's condition takes precedence to ensure the patient's safety and well-being. While documenting the fall and notifying the healthcare provider are essential steps, they come after assessing the patient's injuries.

4. A healthcare provider is assessing a client who reports a possible exposure to HIV. Which of the following findings should the healthcare provider identify as an early manifestation of HIV infection?

Correct answer: B

Rationale: The correct answer is 'B: Fatigue.' Early manifestations of HIV infection often include symptoms like fatigue, fever, and rash, which are typical of viral infections. Stomatitis (choice A) refers to inflammation of the mouth and lips, which can occur in HIV but is not specific to early infection. Wasting syndrome (choice C) and lipodystrophy (choice D) are more commonly associated with later stages of HIV infection rather than early manifestations.

5. Which assessment question asked by the nurse demonstrates an understanding of comorbid mental health conditions associated with major depressive disorder? Select one that doesn't apply.

Correct answer: A

Rationale: Questions about anxiety management, disordered eating, and alcohol use are relevant to identifying comorbid conditions with major depressive disorder, but the question 'Do rules apply to you?' does not directly address common comorbid mental health conditions associated with major depressive disorder.

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