ATI LPN
ATI LPN Level 3 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is reinforcing teaching about the prevention of deep vein thrombosis (DVT) with a group of newly licensed nurses. Which of the following interventions should the nurse include in the teaching?
Correct Answer: B
Rationale: Place sequential compression devices bilaterally. Sequential compression devices (SCDs) help promote venous return and prevent venous stasis, thereby reducing the risk of DVT.
Question 2 of 5
A nurse is caring for a client who has thrombophlebitis and is receiving a continuous infusion of heparin. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse make?
Correct Answer: B
Rationale: Heparin prevents new clots from forming rather than dissolving established clots. Heparin's role is to prevent new clots from forming, not to dissolve existing clots. The body's natural fibrinolytic system will eventually break down the clot.
Question 3 of 5
A nurse is caring for a client who has just been diagnosed with angina pectoris. The client tells the nurse that he is afraid of dying from a heart attack. Which of the following is an appropriate nursing response?
Correct Answer: D
Rationale: Tell me more about these fears. This response is therapeutic and encourages the client to express his concerns and feelings, which is a key part of addressing fear and anxiety.
Question 4 of 5
A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Measure from the client's heel to the popliteal space. For knee-high stockings, measuring from the heel to the popliteal space (behind the knee) ensures the stockings fit properly without cutting off circulation or causing discomfort.
Question 5 of 5
A nurse is contributing to the care plan of a client who is postoperative and has an increased risk for deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan?
Correct Answer: A,B,C,E
Rationale: A. Assist with ordered exercise as needed: Mobility and exercises such as ankle pumps help promote circulation and prevent venous stasis, reducing the risk of DVT. B. Encourage fluids: Encouraging fluids helps prevent dehydration, which reduces blood viscosity and lowers the risk of clot formation. C. Measure affected limb circumference: Measuring limb circumference is important for detecting early signs of DVT, such as swelling in the affected limb. E. Apply compression stockings: Compression stockings promote venous return and reduce the risk of blood pooling in the lower extremities, thus preventing DVT.