Nokea
The LPN/LVN is assisting in the care of a client who has been prescribed enoxaparin (Lovenox) for the prevention of deep vein thrombosis (DVT). Which instruction should the nurse reinforce with the client?
- A. Avoid consuming foods high in vitamin K while taking this medication.
- B. Administer the injection in the same site each time for consistency.
- C. Report any unusual bleeding or bruising to your healthcare provider.
- D. Do not take aspirin if you experience any mild pain or discomfort.
Correct Answer: C
Rationale: The correct instruction for the nurse to reinforce with the client is to report any unusual bleeding or bruising to their healthcare provider. This is important because unusual bleeding or bruising may indicate excessive anticoagulation, a potential side effect of enoxaparin, and should be promptly addressed by a healthcare provider to prevent complications.
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The healthcare professional is assisting in the care of a client diagnosed with deep vein thrombosis (DVT). Which instruction should be reinforced to prevent complications?
- A. Elevate the affected leg using pillows.
- B. Perform leg exercises while sitting.
- C. Wear snug compression stockings.
- D. Avoid applying ice packs to injuries.
Correct Answer: A
Rationale: Elevating the affected leg using pillows is essential in managing deep vein thrombosis (DVT) as it helps reduce swelling and promote venous return, thus decreasing the risk of complications such as pulmonary embolism. This position aids in improving blood circulation and preventing blood clots from forming or worsening in the affected leg.
The healthcare professional is caring for a client who has just returned from a cardiac catheterization. The healthcare professional should prioritize which assessment?
- A. Monitoring the client's vital signs every 4 hours
- B. Assessing the puncture site for bleeding
- C. Encouraging the client to ambulate early to prevent complications
- D. Providing the client with fluids to flush out the contrast dye
Correct Answer: B
Rationale: Assessing the puncture site for bleeding is a critical assessment after a cardiac catheterization procedure. This is essential to detect and address any potential complications promptly, such as hemorrhage or hematoma formation. Monitoring the puncture site helps ensure early intervention and prevent further complications, making it the priority assessment in this situation.
The client with a diagnosis of heart failure is receiving furosemide (Lasix). Which laboratory value is most important for the nurse to monitor?
- A. Blood glucose
- B. Serum sodium
- C. Serum potassium
- D. Blood urea nitrogen (BUN)
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
In monitoring the effectiveness of warfarin therapy for a client with a history of atrial fibrillation, which laboratory value should the nurse monitor?
- A. Activated partial thromboplastin time (aPTT)
- B. Prothrombin time (PT) and international normalized ratio (INR)
- C. Platelet count
- D. Erythrocyte sedimentation rate (ESR)
Correct Answer: B
Rationale: Prothrombin time (PT) and international normalized ratio (INR) are crucial laboratory values to monitor the effectiveness of warfarin therapy in clients with atrial fibrillation. These values help ensure that the client is within the therapeutic range and that the anticoagulant effect of warfarin is appropriate.
After a client with a history of myocardial infarction (MI) is prescribed aspirin, which instruction should the nurse include in the discharge teaching?
- A. Take the aspirin with food to prevent gastrointestinal upset
- B. Discontinue the aspirin if you experience ringing in your ears
- C. Take the aspirin at bedtime to minimize side effects
- D. Avoid taking aspirin if you are also taking other NSAIDs
Correct Answer: A
Rationale: The correct instruction is to take aspirin with food to prevent gastrointestinal upset. Aspirin can irritate the stomach lining, leading to potential gastrointestinal issues. Taking it with food helps reduce this risk by providing a protective layer in the stomach. This is a common recommendation to minimize the risk of gastrointestinal side effects when taking aspirin.