Nokea
Heparin has been ordered for a client with pulmonary embolis. Which statement, if made by the graduate nurse, indicates a lack of understanding of the medication?
- A. I will administer the medication 1-2 inches away from the umbilicus.'
- B. I will administer the medication in the abdomen.'
- C. I will check the PTT before administering the medication.'
- D. I will need to aspirate when I give Heparin.'
Correct Answer: D
Rationale: Aspirating during heparin injection is incorrect, as it increases the risk of hematoma formation in subcutaneous administration.
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The nurse is preparing a client for cataract surgery. The nurse is aware that the procedure will use:
- A. Mydriatics to facilitate removal
- B. Miotic medications such as Timoptic
- C. A laser to smooth and reshape the lens
- D. Silicone oil injections into the eyeball
Correct Answer: A
Rationale: Mydriatics are used to dilate the pupil, facilitating lens removal during cataract surgery.
A client is to be discharged 48 hours after a normal vaginal delivery of an infant with no laceration or episiotomy. Which of the following danger signs should the client be advised to report to her physician? Select all that apply.
- A. Temperature higher than 38°C/100.4°F
- B. Difficulty urinating
- C. Swelling, redness, or pain in one or both legs
- D. Fatigue
- E. Foul-smelling vaginal discharge
Correct Answer: A,B,C,E
Rationale: Postpartum danger signs include fever >38°C (A), difficulty urinating (B), leg swelling/redness/pain (C, indicating possible DVT), and foul-smelling discharge (E, suggesting infection). Fatigue (D) is common and not necessarily a danger sign.
A client with deep vein thrombosis is receiving a continuous heparin infusion and Coumadin PO. INR lab test result is 8.0. Which intervention would be most important to include in the nursing care plan?
- A. Assess for signs of abnormal bleeding
- B. Anticipate an increase in the heparin drip rate
- C. Instruct the client regarding the drug therapy
- D. Increase the frequency of vascular assessments
Correct Answer: A
Rationale: An INR of 8.0 is dangerously high, indicating a risk of bleeding. Assessing for abnormal bleeding is the priority to detect and manage potential complications.
Four 6-month-old children arrive at the clinic for diphtheria-pertussis-tetanus immunization. Which child can safely receive the immunization at this time?
- A. the child with a runny nose
- B. the child who experienced a seizure after the last immunization
- C. the child who experienced a life-threatening allergic reaction after the last immunization
- D. the child with a temperature of 102°F
Correct Answer: A
Rationale: A mild runny nose is not a contraindication for the DTaP vaccine, whereas seizures, severe allergic reactions, or fever indicate a need to delay immunization.
The nurse is preparing to administer a dose of enoxaparin (Lovenox) to a client with a pulmonary embolism. Which of the following actions by the nurse is correct?
- A. Administer the injection in the deltoid muscle.
- B. Massage the injection site after administration.
- C. Inject the medication into the abdomen, at least 2 inches from the umbilicus.
- D. Aspirate before injecting to check for blood return.
Correct Answer: C
Rationale: enoxaparin is administered subcutaneously in the abdomen, at least 2 inches from the umbilicus, without aspiration or massage