Nokea
A client is being discharged with a new prescription for enoxaparin (Lovenox). Which instruction should the nurse include?
- A. Administer the injection in your thigh.
- B. Do not expel the air bubble from the syringe before injection.
- C. Massage the injection site after administration.
- D. Alternate the injection site between the arms.
Correct Answer: B
Rationale: The correct answer is B because expelling the air bubble from the syringe before injection helps ensure accurate dosage delivery and prevents air from being injected into the patient. Administering the injection in the thigh (A) is incorrect as enoxaparin is typically given in the abdomen. Massaging the injection site (C) can cause bruising or hematoma formation. Alternating injection sites between arms (D) is not relevant as enoxaparin is usually given in the abdomen.
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What is the primary advantage of prescribing rivaroxaban over warfarin for a patient with a history of deep vein thrombosis (DVT)?
- A. No need for regular INR monitoring
- B. Lower risk of bleeding
- C. Fewer dietary restrictions
- D. Longer half-life
Correct Answer: A
Rationale: The primary advantage of prescribing rivaroxaban over warfarin for a patient with a history of DVT is the absence of regular INR monitoring required with rivaroxaban. This is because rivaroxaban is a direct oral anticoagulant with more predictable pharmacokinetics, eliminating the need for monitoring. Regular INR monitoring is necessary with warfarin to ensure the drug is within the therapeutic range, which can be burdensome for patients and healthcare providers. The other choices are incorrect as they do not directly address the primary advantage of rivaroxaban over warfarin for this specific patient population.
When covering another nurse's assignment during a lunch break, based on the status report provided, which client should the charge nurse check first?
- A. The client admitted yesterday with diabetic ketoacidosis whose blood glucose level is now 195 mg/dl.
- B. The client with an ileal conduit created two days ago with a scant amount of blood in the drainage pouch.
- C. The client post-triple coronary bypass four days ago who has serosanguinous drainage in the chest tube.
- D. The client with a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90%.
Correct Answer: D
Rationale: The correct answer is D because a pneumothorax with a pulse oximeter reading of 90% indicates potential respiratory compromise, requiring immediate attention to prevent further deterioration. A pneumothorax can lead to decreased oxygenation, which is critical for the client's health and needs prompt intervention. Checking this client first is essential to ensure timely management and prevent any adverse outcomes.
Choice A is incorrect because a blood glucose level of 195 mg/dl in a client with diabetic ketoacidosis, while elevated, does not pose an immediate threat to life compared to respiratory compromise.
Choice B is incorrect as a scant amount of blood in the drainage pouch does not indicate an urgent situation or immediate risk to the client's health.
Choice C is incorrect as serosanguinous drainage in a chest tube post-triple coronary bypass, while requiring monitoring, does not indicate an immediate need for intervention compared to a potential respiratory compromise in choice D.
A client with peptic ulcer disease is prescribed ranitidine (Zantac). Which statement by the client indicates the need for further teaching?
- A. I will take this medication at bedtime.
- B. I need to avoid smoking while taking this medication.
- C. I should take this medication with meals.
- D. This medication will help reduce stomach acid.
Correct Answer: C
Rationale: Rationale:
C is the correct answer. Ranitidine is usually taken on an empty stomach to maximize its effectiveness in reducing stomach acid production. Therefore, taking it with meals would decrease its efficacy. A, B, and D are incorrect because taking ranitidine at bedtime is common practice, smoking can worsen ulcer symptoms, and ranitidine does indeed reduce stomach acid.
The nurse formulates a nursing diagnosis of 'High risk for ineffective airway clearance' for a client with myasthenia gravis. What is the most likely etiology for this nursing diagnosis?
- A. Pain when coughing.
- B. Diminished cough effort.
- C. Thick, dry secretions.
- D. Excessive inflammation.
Correct Answer: B
Rationale: The correct answer is B: Diminished cough effort. In myasthenia gravis, muscle weakness can affect the respiratory muscles, leading to ineffective coughing and clearance of airways. Diminished cough effort can result in ineffective airway clearance, putting the client at high risk for respiratory complications.
A: Pain when coughing is not the primary etiology for ineffective airway clearance in myasthenia gravis.
C: Thick, dry secretions may contribute to airway clearance issues but are not the most likely etiology compared to diminished cough effort.
D: Excessive inflammation is not typically associated with ineffective airway clearance in myasthenia gravis.
The nurse is administering sevelamer (RenaGel) during lunch to a client with end-stage renal disease (ESRD). The client asks the nurse to bring the medication later. The nurse should describe which action of RenaGel as an explanation for taking it with meals?
- A. Prevents indigestion associated with the ingestion of spicy foods.
- B. Binds with phosphorus in foods and prevents absorption.
- C. Promotes stomach emptying and prevents gastric reflux.
- D. Buffers hydrochloric acid and prevents gastric erosion.
Correct Answer: B
Rationale: The correct answer is B. Sevelamer (RenaGel) is a phosphate binder used in ESRD to bind with phosphorus in foods, preventing its absorption in the gastrointestinal tract. This is important as ESRD patients often have high levels of phosphorus in their blood, which can lead to complications like cardiovascular disease. Taking RenaGel with meals ensures that it binds with phosphorus in the food, reducing its absorption.
Choice A is incorrect as RenaGel does not prevent indigestion associated with spicy foods. Choice C is incorrect as RenaGel does not promote stomach emptying or prevent gastric reflux. Choice D is incorrect as RenaGel does not buffer hydrochloric acid or prevent gastric erosion.