Nokea
A nurse is caring for a client who weighs 207 pounds and is started on enoxaparin (Lovenox). How much enoxaparin does the nurse anticipate administering? (Record your answer using a whole number.) __ mg
- A. 90
- B. 80
- C. 100
- D. 70
Correct Answer: A
Rationale: The dose of enoxaparin is 1 mg/kg body weight, not to exceed 90 mg. This client weighs 207 pounds (94 kg), so the nurse anticipates administering the maximum dose of 90 mg.
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The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet?
- A. A 4-ounce steak, French fries, iceberg lettuce
- B. Baked chicken breast, broccoli, tomatoes
- C. Fried catfish, cornbread, peas
- D. Spaghetti with meat sauce, garlic bread
Correct Answer: B
Rationale: The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is baked chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no vegetables.
A nurse is caring for a client on IV infusion of heparin. What actions does the nurse include in the client's plan? (Select all that apply.)
- A. Assess the client for bleeding
- B. Monitor the daily activated partial thromboplastin time (aPTT) results
- C. Stop the IV if aPTT shows baseline
- D. Use an IV pump for the infusion
- E. Weigh the client daily on the same scale
Correct Answer: A,B,D
Rationale: Assessing for bleeding, monitoring aPTT, and using an IV pump are critical for heparin safety. Stopping the IV at baseline aPTT is incorrect, as therapeutic levels are 1.5-2 times baseline. Weighing is not directly related.
A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service?
- A. African-American churches
- B. Asian-American groceries
- C. High school sports camps
- D. Women's health clinics
Correct Answer: A
Rationale: Providing services at African-American churches has the potential to reach this priority population, as African-Americans are at higher risk for hypertension. While hypertension education is important for all groups, this is the priority population for this intervention.
A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority?
- A. Administer prescribed pain medication
- B. Assess distal pulses and skin color
- C. Document the findings in the client's chart
- D. Notify the surgeon immediately
Correct Answer: B
Rationale: Assessing distal pulses and skin color is the priority to ensure adequate circulation post-surgery. Severe pain could indicate complications like graft occlusion. Administering pain medication, documenting, or notifying the surgeon are secondary until circulation is confirmed.
Which factors does the nurse teach as contributing to aneurysm formation? (Select all that apply.)
- A. Atherosclerosis
- B. Down syndrome
- C. Frequent heartburn
- D. History of hypertension
- E. History of smoking
Correct Answer: A,D,E
Rationale: Atherosclerosis, hypertension, and smoking are major risk factors for aneurysm formation. Down syndrome and heartburn are not related.