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The nurse is administering SUBQ enoxaparin to a client following knee replacement surgery to prevent a deep vein thrombosis. Which laboratory result requires immediate action by the nurse?
- A. Platelet count of 100,000/mm3 (100 x 10^9/L).
- B. Serum creatinine 1.0 mg/dL (88.4 μmol/L).
- C. Blood urea nitrogen (BUN) 20 mg/dL (7.1 mmol/L).
- D. Hematocrit 45% (0.45 volume fraction).
Correct Answer: A
Rationale: A platelet count of 100,000/mm3 indicates thrombocytopenia, increasing bleeding risk with enoxaparin, requiring immediate action. Creatinine, BUN, and hematocrit are within normal ranges.
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Based on a client's serum digoxin level, the client is diagnosed with digoxin toxicity. Which action should the nurse expect to implement?
- A. Give digoxin by another route to slow absorption.
- B. Begin cardioversion to stabilize heart rhythm.
- C. Administer potassium to stabilize the heart rate.
- D. Check acid-base and electrolyte values.
Correct Answer: D
Rationale: Checking acid-base and electrolyte values is critical to manage digoxin toxicity, as imbalances like hypokalemia exacerbate toxicity. Changing routes, cardioversion, or potassium administration are not immediate actions without further assessment.
A client who experiences migraine headaches reports having fewer headaches since using the herbal remedy feverfew. Which information is most important for the nurse to include in a teaching plan for this client?
- A. Increased anxiety and nervousness have been reported by those taking feverfew.
- B. Those with allergies to chamomile, ragweed, or yarrow should not take feverfew.
- C. Abdominal pain, gas, nausea, vomiting, and diarrhea can occur when taking feverfew.
- D. Feverfew may interact with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs).
Correct Answer: B
Rationale: Feverfew can cause allergic reactions in individuals allergic to chamomile, ragweed, or yarrow, making this critical to prevent serious reactions. Anxiety, GI effects, or NSAID interactions are less urgent.
The healthcare provider prescribes enoxaparin sodium 80 mg SUBQ twice daily. The nurse is preparing a preloaded 1 mL syringe labeled, 'Enoxaparin sodium injection, USP 60 mg/0.6 mL.' How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)
Correct Answer: 0.8
Rationale: Desired dose = 80 mg, Concentration = 60 mg/0.6 mL = 100 mg/mL. Volume = 80 mg / 100 mg/mL = 0.8 mL.
A female client who is starting a new prescription for doxycycline hyclate tells the nurse that she takes birth control pills. Which action should the nurse take?
- A. Instruct the client to take the two medications at least two hours apart.
- B. Advise the client that the birth control pills will be less effective while taking doxycycline hyclate.
- C. Notify the healthcare provider of the contraindication to tetracyclines.
- D. Encourage the client to stop taking birth control pills until she has finished taking all the doxycycline hyclate.
Correct Answer: B
Rationale: Doxycycline can reduce birth control pill effectiveness, requiring additional contraception. Timing separation, contraindication notification, or stopping birth control are incorrect actions.
Furosemide is prescribed for a client with a history of heart failure (HF). Which foods should the nurse encourage this client to eat?
- A. Cheese, milk, and yogurt.
- B. Liver, beef, and chicken.
- C. Bananas, oranges, and peaches.
- D. Pasta, cereal, and bread.
Correct Answer: C
Rationale: Furosemide causes potassium loss, so potassium-rich foods like bananas, oranges, and peaches should be encouraged. Dairy, meats, and carbohydrates do not address potassium needs.