Nokea
A client is being treated for deep vein thrombosis (DVT) in the left femoral artery. The physician has ordered 60 mg of enoxaparin (Lovenox) subcutaneously. Before administering the drug, the nurse checks the client's laboratory results, noted below. Based on these results, the nurse should:
- A. Assess the client for bleeding
- B. Administer the medication
- C. Inform the physician
- D. Withhold the dose of Lovenox
Correct Answer: C
Rationale: Without specific lab results provided, the context implies abnormal values (e.g., low platelets or high INR) that increase bleeding risk with enoxaparin, a low-molecular-weight heparin. The nurse should inform the physician to evaluate the results before proceeding. Administering or withholding without consultation is unsafe, and assessing for bleeding is not the immediate action.
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The nurse's best explanation for why the severely neutropenic client is placed in reverse isolation is that reverse isolation helps prevent the spread of organisms:
- A. To the client from sources outside the client's environment.
- B. From the client to health care personnel, visitors, and other clients.
- C. By using special techniques to dispose of contaminated materials.
- D. By using special techniques to handle the client's linens and personal items.
Correct Answer: A
Rationale: Reverse isolation protects severely neutropenic clients by preventing the introduction of pathogens from external sources, such as staff, visitors, or equipment. It is not about preventing spread from the client or specific disposal/handling techniques.
What is the purpose of straining urine in a client with renal calculi?
- A. Detect blood.
- B. Identify stone composition.
- C. Measure urine volume.
- D. Prevent infection.
Correct Answer: B
Rationale: Straining urine captures stones for analysis to determine composition.
Which complication should the nurse monitor for in a client with a new ileal conduit?
- A. Stoma prolapse.
- B. Urinary retention.
- C. Bladder spasms.
- D. Renal colic.
Correct Answer: A
Rationale: Stoma prolapse is a potential complication of an ileal conduit, requiring surgical correction if severe.
Which of the following nursing interventions will be most effective when caring for a client who is experiencing powerlessness?
- A. Make certain that all staff members focus only on the client's capabilities.
- B. Encourage family members to become more responsible for the client's care.
- C. Request a referral to a psychologist.
- D. Include the client in decision making whenever possible.
Correct Answer: D
Rationale: Including the client in decision-making empowers them, reducing feelings of powerlessness by restoring a sense of control.
A client with acute renal failure has metabolic acidosis. The nurse expects:
- A. Sodium bicarbonate administration.
- B. Increased potassium intake.
- C. Fluid bolus.
- D. High-protein diet.
Correct Answer: A
Rationale: Sodium bicarbonate corrects metabolic acidosis in acute renal failure.