what is the most important nursing intervention for a patient with suspected dvt

ATI RN

ATI RN Exit Exam Quizlet

1. What is the most important intervention for a patient with suspected DVT?

A. Administer anticoagulants
B. Monitor oxygen levels
C. Apply compression stockings
D. Encourage ambulation

Correct answer: A

Rationale: The correct answer is to administer anticoagulants. Administering anticoagulants is crucial in the management of deep vein thrombosis (DVT) as it helps prevent the clot from growing larger or dislodging, potentially causing a life-threatening pulmonary embolism. While monitoring oxygen levels, applying compression stockings, and encouraging ambulation are important aspects of DVT management, administering anticoagulants is the most critical intervention to prevent further complications.

2. A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following actions should the nurse take?

A. Insert the catheter until urine flows, then advance 2.5 to 5 cm (1 to 2 in) further.
B. Advance the catheter 7.5 to 10 cm (3 to 4 in) after urine begins to flow.
C. Advance the catheter 17 to 22.5 cm (7 to 9 in) after urine begins to flow.
D. Advance the catheter 5 to 7.5 cm (2 to 3 in) after urine begins to flow.

Correct answer: C

Rationale: When inserting an indwelling urinary catheter for a male client, it is crucial to advance the catheter 17 to 22.5 cm after urine begins to flow. This helps ensure proper placement in the male urethra, which is longer compared to females. Choice A is incorrect as advancing only 2.5 to 5 cm would not reach the correct placement in male clients. Choice B is incorrect as advancing 7.5 to 10 cm is insufficient to reach the appropriate location in male clients. Choice D is also incorrect as advancing 5 to 7.5 cm would likely not reach the desired placement in male clients.

3. A nurse is assessing a client who has chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse report to the provider?

A. Oxygen saturation of 91%
B. Use of pursed-lip breathing
C. Productive cough with green sputum
D. Decreased breath sounds in the right lower lobe

Correct answer: D

Rationale: The correct finding the nurse should report to the provider is decreased breath sounds in the right lower lobe. This can indicate a respiratory infection or atelectasis in clients with COPD, requiring further evaluation and intervention. Choice A, an oxygen saturation of 91%, although slightly lower than normal, does not necessarily require immediate reporting unless the client's baseline is significantly higher. Choice B, the use of pursed-lip breathing, is actually a beneficial technique for clients with COPD to improve oxygenation and reduce shortness of breath, so it does not need reporting. Choice C, a productive cough with green sputum, can be common in clients with COPD and may indicate an infection, but it is not as concerning as decreased breath sounds in a specific lung lobe which may signify a more acute issue.

4. How should a healthcare provider care for a patient with a tracheostomy?

A. Clean the tracheostomy site daily
B. Change the tracheostomy ties daily
C. Suction the tracheostomy regularly
D. Provide humidified oxygen

Correct answer: C

Rationale: Suctioning the tracheostomy regularly is crucial in caring for a patient with a tracheostomy as it helps keep the airway clear of secretions, preventing blockages and potential complications. Cleaning the tracheostomy site daily is important for hygiene but not as critical as regular suctioning. Changing the tracheostomy ties daily may not be necessary unless soiled or loose. Providing humidified oxygen may be part of the care plan but is not as directly related to maintaining the tracheostomy patency as suctioning.

5. A nurse is reviewing laboratory results for a client who has rheumatoid arthritis and is prescribed methotrexate. Which of the following results should the nurse report to the provider?

A. White blood cell count 8,000/mm³
B. Platelet count 150,000/mm³
C. Hemoglobin 14 g/dL
D. Aspartate aminotransferase (AST) 60 units/L

Correct answer: D

Rationale: The correct answer is D: Aspartate aminotransferase (AST) 60 units/L. An elevated AST level indicates liver damage, which can be a side effect of methotrexate and should be reported. Elevated white blood cell count (choice A), platelet count (choice B), or normal hemoglobin level (choice C) are not directly related to methotrexate therapy for rheumatoid arthritis.