Nokea
A client is to receive enoxaparin (Lovenox) 6 hours before the scheduled time of her laparoscopic vaginal assisted hysterectomy. Which of the following effects does the nurse recognize as an intended therapeutic action of the enoxaparin?
- A. Increase in red blood cell production.
- B. Reduction of postoperative thrombi.
- C. Decrease in postoperative bleeding.
- D. Promotion of tissue healing.
Correct Answer: B
Rationale: Enoxaparin is an anticoagulant that prevents postoperative thrombi by inhibiting clot formation, reducing the risk of deep vein thrombosis or pulmonary embolism.
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A client receiving chemotherapy has experienced a flare-up of pruritus. In order to develop a care plan, the nurse should ask the client if she has been:
- A. Wearing clothes made from 100% cotton.
- B. Sleeping in a cool, humidified room.
- C. Increasing fluid intake to at least 3,000 mL/day.
- D. Taking daily baths with a deodorant soap.
Correct Answer: B
Rationale: Sleeping in a cool, humidified room can reduce pruritus by preventing skin dryness, which is a key factor in developing an effective care plan.
Which lab result indicates worsening acute renal failure?
- A. Creatinine 3.5 mg/dL.
- B. BUN 20 mg/dL.
- C. Potassium 4.0 mEq/L.
- D. Sodium 140 mEq/L.
Correct Answer: A
Rationale: Elevated creatinine indicates reduced kidney function in acute renal failure.
Which of the following laboratory findings would the nurse expect to find in a client with diverticulitis?
- A. Elevated red blood cell count.
- B. Decreased platelet count.
- C. Elevated white blood cell count.
- D. Elevated serum blood urea nitrogen concentration.
Correct Answer: C
Rationale: Diverticulitis, an inflammatory condition, typically causes an elevated white blood cell count due to infection or inflammation. Red blood cell count, platelet count, and blood urea nitrogen are not directly affected. CN: Physiological adaptation; CL: Analyze
A client who was in a motor vehicle accident has a fractured mandible. Surgery has been performed to immobilize the injury by wiring the jaw. In the immediate postoperative phase, the nurse should:
- A. Prevent nausea and vomiting.
- B. Maintain a patent airway.
- C. Provide frequent oral hygiene.
- D. Establish a way for the client to communicate.
Correct Answer: B
Rationale: Maintaining a patent airway is the priority in the immediate postoperative phase for a client with a wired jaw, as swelling or secretions could obstruct the airway. While the other interventions are important, airway management is the most critical.
Which position is best for a client with a hemorrhagic stroke?
- A. Flat supine.
- B. Head elevated 30 degrees.
- C. Prone position.
- D. Trendelenburg position.
Correct Answer: B
Rationale: Head elevation at 30 degrees reduces intracranial pressure while maintaining cerebral perfusion in hemorrhagic stroke.