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The nurse is administering SUBQ enoxaparin to a client following knee replacement surgery to prevent a deep vein thrombosis. Which laboratory result requires immediate action by the nurse?
- A. Platelet count of 100,000/mm3 (100 x 10^9/L).
- B. Serum creatinine 1.0 mg/dL (88.4 μmol/L).
- C. Blood urea nitrogen (BUN) 20 mg/dL (7.1 mmol/L).
- D. Hematocrit 45% (0.45 volume fraction).
Correct Answer: A
Rationale: A platelet count of 100,000/mm3 indicates thrombocytopenia, increasing bleeding risk with enoxaparin, requiring immediate action. Creatinine, BUN, and hematocrit are within normal ranges.
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A young adult female client who is planning to become pregnant asks the nurse if she can continue taking isotretinoin for cystic acne. Which information is most important for the nurse to provide this client?
- A. Breastfeeding is not recommended while taking this medication.
- B. Do not take multiple vitamins that contain vitamin A while taking this drug.
- C. Baseline liver function results must be obtained during therapy.
- D. Discontinue this medication one month before attempting to conceive.
Correct Answer: D
Rationale: Isotretinoin is highly teratogenic, requiring discontinuation at least one month before conception to prevent birth defects. Breastfeeding, vitamin A, and liver monitoring are secondary concerns.
The nurse is assessing the client to update the plan of care.Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. "The nurse determines that the client's is experiencing -----------, and the blood pressure changes are the result of-------------------.
- A. Adverse drug reaction
- B. Antibiotic
- C. Syncope
- D. Heart failure
- E. IV infiltration
Correct Answer: A,B
Rationale: The client’s symptoms (dizziness, hives, etc.) indicate an adverse reaction (Red Man Syndrome) to vancomycin, causing hypotension. Both blanks are correctly filled by 'Adverse drug reaction' and 'Antibiotic' (vancomycin).
A female client with mild depression reports to the nurse recently starting St. John's wort. Which information provided by the client requires further instruction?
- A. Hard candy can be used for a dry mouth.
- B. Insomnia may occur while taking the medication.
- C. Another form of contraception is not needed.
- D. Sensitivity to the sun can develop.
Correct Answer: C
Rationale: St. John's wort reduces oral contraceptive effectiveness, necessitating additional contraception. Dry mouth relief, insomnia, and photosensitivity are correct understandings.
A client who is receiving pregabalin for fibromyalgia complains of tremors in the hands. Which action should the nurse implement?
- A. Notify the healthcare provider.
- B. Administer a PRN dose of an antianxiety drug.
- C. Obtain orthostatic blood pressure readings.
- D. Collect a capillary glucose level.
Correct Answer: A
Rationale: Tremors are a potential side effect of pregabalin, warranting notification of the healthcare provider for possible dose adjustment. Antianxiety drugs, blood pressure readings, or glucose levels are not directly related to addressing pregabalin-induced tremors.
The nurse is providing discharge instructions for a client with metastatic cancer who is prescribed morphine for bone pain. Which information from the client indicates to the nurse an understanding of the medication?
- A. Observe bowel movement pattern and take a stool softener.
- B. Watch for signs of agitation and record any insomnia.
- C. Take the benzodiazepine at the same time as taking the morphine.
- D. Do not drink grapefruit juice after taking morphine.
Correct Answer: A
Rationale: Morphine causes constipation, so monitoring bowel movements and using a stool softener demonstrates understanding. Agitation/insomnia, benzodiazepine timing, and grapefruit juice are not primary concerns.