the nurse is assessing an immobile patient for deep vein thrombosis dvt what should the nurse do the nurse is assessing an immobile patient for deep vein thrombosis dvt what should the nurse do
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Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. The healthcare provider is assessing an immobile patient for deep vein thrombosis (DVT). What should the healthcare provider do?

Correct answer: C

Rationale: Measuring the calf circumference of both legs is crucial when assessing for DVT in an immobile patient. A significant increase in the circumference of one calf compared to the other suggests the presence of a deep vein thrombosis. Option A is incorrect because rubbing the lower leg may dislodge a clot if present. Option B is incorrect as elastic stockings should not be removed frequently as this can increase the risk of clot formation. Option D is incorrect as dorsiflexing the foot can lead to pain and should not be done to assess for DVT.

2. While on Bryant’s traction, which of these observations of Graciela and her traction apparatus would indicate a decrease in the effectiveness of her traction?

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

3. How should the nurse respond to a 72-year-old patient diagnosed with benign prostatic hypertrophy (BPH) who is skeptical about tamsulosin (Flomax) for symptom relief?

Correct answer: B

Rationale: The correct response is choice B because it explains the mechanism of action of Flomax, which helps the patient understand how the medication works. By stating that Flomax relaxes the prostate and bladder neck, making it easier to pass urine, the nurse is addressing the patient's concerns about symptom relief. Choices A, C, and D provide inaccurate information about Flomax's mechanism of action and do not directly address the patient's skepticism or concerns.

4. How are antibodies produced?

Correct answer: A

Rationale: Antibodies are produced by B cells. B cells are specialized white blood cells that generate antibodies as part of the immune response. B cells differentiate into plasma cells that secrete antibodies. T cells play a role in cell-mediated immunity, not antibody production. Helper cells, or helper T cells, assist in activating B cells but do not directly produce antibodies. Memory cells store information about previous infections but do not actively produce antibodies.

5. A nurse is teaching a client who has fibromyalgia about strategies that might help reduce her symptoms. What should the nurse include in the client education?

Correct answer: Establish a regular sleep pattern

Rationale:

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