Nokea
A nurse is caring for a client prescribed enoxaparin for deep vein thrombosis prophylaxis. Which of the following client assessments requires immediate intervention?
- A. Platelet count of 95,000/mm³
- B. Blood pressure of 145/90 mmHg
- C. Heart rate of 95 beats per minute
- D. Pain at the injection site
Correct Answer: A
Rationale: A platelet count of 95,000/mm³ requires immediate intervention as it is low and increases the risk of bleeding, which is a potential complication of enoxaparin therapy. Low platelet counts can predispose the patient to hemorrhage, and administering anticoagulants like enoxaparin in such cases can further increase the bleeding risk. Monitoring platelet counts is crucial during anticoagulant therapy to prevent serious bleeding complications. The other options do not pose immediate risks related to enoxaparin therapy. A slightly elevated blood pressure, a heart rate of 95 beats per minute, and pain at the injection site are common findings that may not warrant immediate intervention in this context.
You may also like to solve these questions
A nurse is caring for a client with diabetes and a new prescription for 14 units of regular insulin and 28 units of NPH insulin subcutaneously at breakfast daily. What is the total number of units of insulin that the nurse should prepare in the insulin syringe?
- A. 14 units
- B. 28 units
- C. 32 units
- D. 42 units
Correct Answer: D
Rationale: The nurse should combine both orders of insulin in the same syringe. To prepare the correct dose, the nurse should withdraw the regular insulin first (14 units) and then the NPH insulin (28 units), totaling 42 units. This combination ensures the client receives the prescribed doses of both types of insulin. Choices A, B, and C are incorrect because the nurse needs to prepare and administer both types of insulin as prescribed, resulting in a total of 42 units in the syringe.
A client has been prescribed isosorbide mononitrate. Which of the following should the nurse include in the client education related to this medication?
- A. This medication is prescribed for long-term therapy prophylaxis against anginal attacks
- B. Do not crush this medication
- C. Take the medication in the evening after dinner
- D. Do not take an additional tablet if you experience chest pain
Correct Answer: A
Rationale: The correct answer is A because isosorbide mononitrate is used for long-term prophylaxis against anginal attacks. Choice B is incorrect because isosorbide mononitrate should not be crushed. Choice C does not specify a particular time for medication administration. Choice D is incorrect because isosorbide mononitrate is not meant to be taken as needed for chest pain; it is part of a long-term therapy plan.
A client with an artificial heart valve is prescribed warfarin therapy. Which of the following laboratory values should the nurse monitor to assess the therapeutic effect of warfarin?
- A. Hemoglobin (Hgb)
- B. Prothrombin time (PT)
- C. Bleeding time
- D. Activated partial thromboplastin time (aPTT)
Correct Answer: B
Rationale: The correct answer is B: Prothrombin time (PT). Warfarin is an anticoagulant medication that works by inhibiting the clotting factors dependent on vitamin K, such as factors II, VII, IX, and X. The prothrombin time (PT) measures the extrinsic pathway and is used to monitor the therapeutic effects of warfarin therapy. Monitoring PT helps assess the time it takes for the blood to clot, ensuring that the anticoagulant effect is within the desired range. Choices A, C, and D are incorrect because hemoglobin (Hgb) measures the amount of hemoglobin in the blood, bleeding time assesses the time it takes for bleeding to stop, and activated partial thromboplastin time (aPTT) is used to monitor heparin therapy, not warfarin therapy.
A nurse is providing client education on how to administer insulin. Which of the following instructions should the nurse include?
- A. Administer the insulin into the deltoid muscle
- B. Rotate injection sites to prevent lipodystrophy
- C. Massage the site after injection
- D. Use the same site for each injection
Correct Answer: B
Rationale: The correct instruction for administering insulin is to rotate injection sites to prevent lipodystrophy, a common complication of insulin therapy. Injecting into the deltoid muscle (Choice A) is not recommended for insulin injections. Massaging the site after injection (Choice C) is not necessary and can potentially increase the risk of lipodystrophy. Using the same site for each injection (Choice D) can lead to localized tissue damage and absorption irregularities, making it an incorrect choice.
A nurse has provided education to a client regarding prescribed levothyroxine sodium. Which of the following client statements demonstrates understanding of medication administration?
- A. I should take my medication as needed to alleviate symptoms
- B. I should take the medication in divided doses to ensure therapeutic drug levels
- C. I should take the medication in the morning to prevent insomnia
- D. I should take the medication on a full stomach
Correct Answer: C
Rationale: Levothyroxine should be taken once in the morning to prevent insomnia and maintain therapeutic levels.