Nokea
A client is to be discharged on enoxaparin (Lovenox) for the next two days. Which comment by the client indicates a need for further instruction?
- A. I will wash my hands before I prepare the injection.
- B. I will give the injection in my thigh.
- C. I will pinch the skin before I inject the medicine.
- D. I will not massage the area after the shot.
Correct Answer: B
Rationale: Enoxaparin is injected subcutaneously in the abdomen, not the thigh, indicating a need for further teaching.
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The hospice nurse is providing end-of-life care to a client who is experiencing anorexia and cachexia. Which interventions are appropriate? Select all that apply.
- A. Allow the client to refuse food if not feeling hungry
- B. Ask if the client is experiencing any pain or nausea
- C. Involve the client in meal planning and food selection
- D. Plan for loved ones to share mealtimes with the client
- E. Provide oral care before and after meals to alleviate dry mouth
Correct Answer: A,B,D,E
Rationale: Allowing food refusal (A) respects autonomy, assessing pain/nausea (B) addresses barriers to eating, shared mealtimes (D) provide comfort, and oral care (E) improves appetite. Meal planning (C) may overwhelm a cachectic client.
The nurse is preparing to administer IV cefazolin to a newly admitted client with cellulitis. The nurse notes the client is allergic to amoxicillin. Which of the following actions should the nurse take next?
- A. Administer the medication as prescribed.
- B. Administer diphenhydramine before administering cefazolin.
- C. Notify the pharmacy that the medication is not appropriate for the client.
- D. Ask the client for more information about the allergic reaction to amoxicillin.
Correct Answer: D
Rationale: Clients with an allergy to penicillin antibiotics (eg, amoxicillin) can experience a cross-sensitivity reaction
to cephalosporin antibiotics (eg, cefazolin) because the medication molecules are structurally similar. The
nurse should first obtain more information by asking about the type of reaction the client experienced because
allergic reactions can range from mild to severe (Option 4)
Cephalosporins can be safely administered to clients with a history of mild allergic reaction to penicillin (eg,
rash) but are contraindicated for clients with a history of anaphylaxis.
A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?
- A. Blood pressure 94/60
- B. Heart rate 76 BPM
- C. Urine output 50 ml/hour
- D. Respiratory rate 16
Correct Answer: A
Rationale: Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100 BPM; systolic B/P over 100) in order to safely administer both medications.
The nurse is caring for a client with panic disorder who is reporting palpitations and intense feelings of fear. The client is shaking and hyperventilating. Which of the following actions would be a priority for the nurse to take?
- A. Assess the client for auditory and visual hallucinations.
- B. Administer a benzodiazepine to the client.
- C. Explore possible triggers for the episode with the client
- D. Remain in the room with the client.
Correct Answer: D
Rationale: Staying with the client (D) provides safety and reassurance, reducing fear and hyperventilation during a panic attack. Hallucinations (A) are not typical, medication (B) is secondary, and exploring triggers (C) is appropriate after stabilization.
A client diagnosed with endometrial cancer is receiving brachytherapy. Which interventions should the nurse anticipate for this client? Select all that apply.
- A. Cluster care to limit each staff member's time in the room
- B. Instruct the client to be up and around in the room but not to leave the room
- C. Remind family members and visitors to limit close contact with the client
- D. Use protective shielding, if available, when providing direct client care
- E. Wear a radiation badge while in the client's room to measure radiation exposure
Correct Answer: A,C,D,E
Rationale: Brachytherapy involves internal radiation, requiring precautions to minimize exposure. Clustering care (A) reduces staff exposure time. Limiting visitor contact (C) protects others from radiation. Protective shielding (D) and radiation badges (E) ensure safety and monitor exposure. Ambulation (B) is restricted to prevent dislodging the radiation source.