Nokea
The client on bedrest is receiving enoxaparin (Lovenox), a low molecular weight heparin. Which anatomical site is recommended for administering this medication?
- A. The abdominal wall one (1) inch away from the umbilicus.
- B. The vastus lateralis with a 23-gauge needle.
- C. In the deltoid area subcutaneously.
- D. In the anterolateral abdomen.
Correct Answer: D
Rationale: Enoxaparin is injected subcutaneously in the anterolateral abdomen for optimal absorption and minimal bruising, per manufacturer guidelines.
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A client newly diagnosed with Type I Diabetes Mellitus asks the purpose of the test measuring glycosylated hemoglobin. The nurse should explain that the purpose of this test is to determine:
- A. The presence of anemia often associated with Diabetes
- B. The oxygen carrying capacity of the client's red cells
- C. The average blood glucose for the past 2-3 months
- D. The client's risk for cardiac complications
Correct Answer: C
Rationale: The average blood glucose for the past 2-3 months. By testing the portion of the hemoglobin that absorbs glucose, it is possible to determine the average blood glucose over the life span of the red cell, 120 days.
The client diagnosed with migraine headaches is prescribed propranolol (Inderal), a beta blocker, for prophylaxis. Which information should the nurse teach the client?
- A. Instruct to take the medication at the first sign of headache.
- B. Teach the client to take his or her radial pulse for one (1) minute.
- C. Explain this drug may make the client thirsty and have a dry mouth.
- D. Discuss the need to increase artificial light in the home.
Correct Answer: B
Rationale: Propranolol can cause bradycardia; teaching pulse monitoring ensures safety. It’s prophylactic, not acute, and dry mouth or lighting are unrelated.
The client is diagnosed with essential hypertension and is receiving a calcium channel blocker. Which assessment data would warrant the nurse holding the client's medication?
- A. The client's oral temperature is 102°F.
- B. The client complains of a dry, nonproductive cough.
- C. The client's blood pressure reading is 106/76.
- D. The client complains of being dizzy when getting out of bed.
Correct Answer: D
Rationale: Dizziness on standing suggests orthostatic hypotension, a calcium channel blocker side effect, warranting holding the dose to prevent falls. Fever, cough, or BP are less critical.
The male client with a chronic urinary tract infection is prescribed trimethoprim-sulfamethoxazole (Bactrim). Which statement indicates the client needs more teaching?
- A. I will drink six (6) to eight (8) glasses of water a day.
- B. I am going to have to take this medication forever.
- C. I can stop taking this medication if there is no more burning.
- D. I may get diarrhea with this medication, but I can take Imodium.
Correct Answer: C
Rationale: Stopping Bactrim when symptoms resolve risks incomplete treatment and resistance; full course is needed. Hydration, duration, and diarrhea management are correct.
The nurse administers 18 units of Humulin N, an intermediate-acting insulin, at 1630. Which priority intervention should the nurse implement?
- A. Monitor the client's hemoglobin A1c.
- B. Make sure the client eats the evening meal.
- C. Check the a.c. blood glucometer reading.
- D. Ensure the client eats a snack.
Correct Answer: B
Rationale: Humulin N peaks in 4–12 hours; evening meal prevents hypoglycemia during peak action. A1c, a.c. checks, or snacks are less immediate.