Nokea
A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse?
- A. Assessing the client's platelet count
- B. Choosing an 18-gauge, 2-inch needle
- C. Not aspirating prior to injection
- D. Swabbing the injection site with alcohol
Correct Answer: B
Rationale: Enoxaparin is administered subcutaneously, requiring a smaller needle (e.g., 25"?26 gauge, 5/8 inch). An 18-gauge, 2-inch needle is inappropriate and could cause harm.
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The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.)
- A. Adherence to proper hand hygiene
- B. Administering anti-ulcer medication
- C. Elevating the head of the bed
- D. Providing oral care per protocol
- E. Suctioning the client on a regular schedule
Correct Answer: A,B,C,D
Rationale: The ventilator bundle to prevent ventilator-associated pneumonia includes hand hygiene, anti-ulcer medications, elevating the head of the bed (30"?45 degrees), and frequent oral care. Suctioning is performed as needed, not on a fixed schedule.
A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority?
- A. Alteplase (Activase)
- B. Enoxaparin (Lovenox)
- C. Unfractionated heparin
- D. Warfarin sodium (Coumadin)
Correct Answer: A
Rationale: Alteplase is a thrombolytic indicated for large pulmonary embolisms with hemodynamic instability to rapidly dissolve the clot and restore circulation.
The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.)
- A. Chest wall stiffness
- B. Decreased muscle strength
- C. Inability to cooperate
- D. Less lung elasticity
- E. Poor vision and hearing
Correct Answer: A,B,D
Rationale: Age-related changes like chest wall stiffness, decreased muscle strength, and reduced lung elasticity impair weaning from mechanical ventilation. Inability to cooperate and sensory deficits are not universal in older adults.
A client is brought to the emergency department after sustaining injuries in a severe car crash. The client does not appear to be moving normally with respirations, oxygen saturation is 92%. What action by the nurse is best?
- A. Administer oxygen via non-rebreather mask
- B. Perform a rapid trauma assessment
- C. Prepare for chest tube insertion
- D. Obtain a chest X-ray immediately
Correct Answer: A
Rationale: The client's abnormal respiratory movement and low oxygen saturation suggest a traumatic chest injury, possibly pneumothorax or hemothorax. Administering oxygen via a non-rebreather mask is the priority to address hypoxia while further assessment is conducted.
A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred?
- A. Hemoglobin: 14.2 g/dL
- B. Platelet count: 82,000/µL
- C. Red blood cell count: 5.8 million/µL
- D. White blood cell count: 8.7/µL
Correct Answer: B
Rationale: A platelet count of 82,000/µL is low and may indicate heparin-induced thrombocytopenia (HIT), a serious side effect of heparin therapy. The other laboratory values are within normal ranges and do not suggest a serious adverse effect.