a nurse is reviewing the medical record of a client who is receiving heparin to treat deep vein thrombosis dvt which of the following findings should

ATI RN

ATI Exit Exam

1. A nurse is reviewing the medical record of a client who is receiving heparin to treat deep vein thrombosis (DVT). Which of the following findings should the nurse report to the provider?

A. aPTT of 38 seconds
B. Hemoglobin of 15 g/dL
C. Platelet count of 80,000/mm3
D. INR of 1.0

Correct answer: C

Rationale: A platelet count of 80,000/mm3 is below the normal range and should be reported to the provider due to the risk of bleeding. Heparin can cause a rare but serious side effect known as heparin-induced thrombocytopenia, leading to a decrease in platelet count and an increased risk of bleeding. The aPTT of 38 seconds, hemoglobin of 15 g/dL, and an INR of 1.0 are within normal ranges and not directly concerning in this scenario. Platelet count is crucial to monitor in clients receiving heparin therapy to ensure adequate clotting function and prevent bleeding complications.

2. 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.

3. Which lab value should be monitored in patients receiving furosemide?

A. Monitor potassium levels
B. Monitor sodium levels
C. Monitor calcium levels
D. Monitor glucose levels

Correct answer: A

Rationale: The correct answer is to monitor potassium levels in patients receiving furosemide. Furosemide is a loop diuretic that can lead to potassium loss in the urine, potentially causing hypokalemia. Monitoring potassium levels is crucial to prevent complications associated with low potassium levels, such as cardiac arrhythmias. Monitoring sodium levels (choice B) is not typically necessary with furosemide use, as it primarily affects potassium levels. Calcium levels (choice C) and glucose levels (choice D) are not directly impacted by furosemide and require monitoring for other conditions or medications.

4. A nurse is caring for a client who has a prescription for a high-protein diet. Which of the following foods should the nurse recommend?

A. Almonds
B. Cheddar cheese
C. Chicken breast
D. Pasta

Correct answer: C

Rationale: Chicken breast is an excellent choice for a high-protein diet as it is a lean source of protein. Almonds, while a good source of protein, also contain high amounts of fat. Cheddar cheese is high in protein but also high in saturated fat. Pasta is not a significant source of protein compared to chicken breast.

5. What is the best method to monitor fluid balance in a patient receiving diuretics?

A. Monitor daily weight
B. Monitor intake and output
C. Monitor blood pressure
D. Monitor edema

Correct answer: A

Rationale: The best method to monitor fluid balance in a patient receiving diuretics is to monitor daily weight. Daily weighing is a precise way to assess changes in fluid status as it reflects variations in total body water. Monitoring intake and output (choice B) is also important but may not provide as accurate a measurement as daily weight. Monitoring blood pressure (choice C) is essential but does not directly measure fluid balance. Monitoring edema (choice D) is helpful to assess fluid status visually but may not be as sensitive as daily weight measurements in detecting subtle changes in fluid balance.