Nokea
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 client with chronic asthma receives a prescription for montelukast, a leukotriene modifier. Which statement by the client indicates to the nurse that medication teaching was effective?
- A. I should take this medication only when I am having an asthma attack.
- B. I will not need to use my inhalers twice a day when I start this medicine.
- C. This medication will stop an asthma attack immediately.
- D. I will take the tablet every evening to control my asthma.
Correct Answer: D
Rationale: Montelukast is a maintenance medication taken regularly (often in the evening) to control asthma. It is not for acute attacks or to replace inhalers, indicating the client understands its role.
A client with cystitis receives a prescription for phenazopyridine. Which information should the nurse explain to the client about its therapeutic effect?
- A. Provides an analgesic effect for irritated bladder mucosa.
- B. Eliminates urinary bacteria.
- C. Calms spasms in the urinary tract.
- D. Use the medication after voiding after sexual intercourse.
Correct Answer: A
Rationale: Phenazopyridine is a urinary analgesic that relieves pain, burning, and discomfort from irritated bladder mucosa in cystitis. It does not have antibacterial properties, calm spasms, or require specific timing related to sexual intercourse.
A client who experiences migraine headaches reports having fewer headaches since using the herbal remedy feverfew. Which information is most important for the nurse to include in a teaching plan for this client?
- A. Increased anxiety and nervousness have been reported by those taking feverfew.
- B. Those with allergies to chamomile, ragweed, or yarrow should not take feverfew.
- C. Abdominal pain, gas, nausea, vomiting, and diarrhea can occur when taking feverfew.
- D. Feverfew may interact with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs).
Correct Answer: B
Rationale: Feverfew can cause allergic reactions in individuals allergic to chamomile, ragweed, or yarrow, making this critical to prevent serious reactions. Anxiety, GI effects, or NSAID interactions are less urgent.
Furosemide is prescribed for a client with a history of heart failure (HF). Which foods should the nurse encourage this client to eat?
- A. Cheese, milk, and yogurt.
- B. Liver, beef, and chicken.
- C. Bananas, oranges, and peaches.
- D. Pasta, cereal, and bread.
Correct Answer: C
Rationale: Furosemide causes potassium loss, so potassium-rich foods like bananas, oranges, and peaches should be encouraged. Dairy, meats, and carbohydrates do not address potassium needs.
A client is receiving miotics for the treatment of open-angle glaucoma. The nurse determines that a priority nursing problem is 'risk for injury.' This nursing problem is based on which etiology?
- A. Increased frequency of lacrimation.
- B. Decreased night vision.
- C. Increased sensitivity to light.
- D. Diminished color perception.
Correct Answer: B
Rationale: Miotics constrict the pupil, reducing night vision and increasing injury risk in low-light conditions. Lacrimation, photophobia, and color perception changes are less directly linked to injury risk.