how should a nurse monitor a patient with suspected deep vein thrombosis dvt
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Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam 2023

1. How should a healthcare provider monitor a patient with suspected deep vein thrombosis (DVT)?

Correct answer: A

Rationale: The correct way for a healthcare provider to monitor a patient with suspected deep vein thrombosis (DVT) is to check for leg swelling. Leg swelling is a common symptom of DVT and monitoring for this sign is crucial for early detection and intervention. Encouraging ambulation may be beneficial for preventing DVT but is not the recommended method for monitoring an existing condition. Checking for redness may be useful in cases of superficial thrombophlebitis but is not specific to DVT. Monitoring oxygen saturation is more relevant for respiratory or cardiovascular conditions, not for DVT.

2. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?

Correct answer: C

Rationale: Obtaining a prescription for restraint within 4 hours is the correct action when managing restraints in a client with acute mania. This timeframe ensures that the use of restraints is promptly evaluated and authorized by a healthcare provider. Requesting a renewal of the prescription every 8 hours (Choice A) is not necessary and may delay appropriate care. Checking the client's peripheral pulse rate every 30 minutes (Choice B) is important but not the immediate priority when dealing with obtaining a prescription for restraints. Documenting the client's condition every 15 minutes (Choice D) is essential for monitoring, but the priority is to secure a prescription for restraints promptly.

3. A nurse is assessing a client who has been taking lithium for bipolar disorder. Which of the following findings should the nurse report to the provider?

Correct answer: A

Rationale: Corrected Rationale: Tremors can indicate lithium toxicity, which should be reported to the provider for further evaluation. Tremors are a significant sign of lithium toxicity and can lead to serious complications if not addressed promptly. Increased thirst, weight gain, and diarrhea are common side effects of lithium but are not typically indicative of toxicity. Therefore, the nurse should prioritize reporting tremors as it requires immediate attention.

4. A nurse is planning care for a client who has chronic kidney disease. The nurse should identify which of the following laboratory values as an indication for hemodialysis?

Correct answer: A

Rationale: A glomerular filtration rate of 14 mL/minute indicates severe kidney dysfunction, necessitating hemodialysis. The other options, BUN of 16 mg/dL, serum magnesium of 1.8 mg/dL, and serum phosphorus of 4.0 mg/dL, are within normal ranges and do not serve as indications for hemodialysis.

5. A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct method for measuring an infant's temperature is by placing the tip of the thermometer under the center of the infant's axilla (armpit). This method is non-invasive and safe. Pulling the pinna of the ear forward is used when taking a tympanic temperature. Inserting the probe into the rectum is done for rectal temperature measurement, which is not recommended as an initial method in infants. Inserting the thermometer in front of the infant's tongue is not a standard method for measuring temperature in infants.

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