Nokea
The nurse is preparing to administer a dose of enoxaparin (Lovenox) to a client. Which injection site is most appropriate?
- A. Deltoid muscle
- B. Ventrogluteal muscle
- C. Anterolateral thigh
- D. Abdomen, 2 inches from the umbilicus
Correct Answer: D
Rationale: Enoxaparin, a low-molecular-weight heparin, is administered subcutaneously in the abdomen, 2 inches from the umbilicus, to ensure consistent absorption and minimize bruising. Muscle injections are inappropriate.
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The nurse is preparing to check a client for Trousseau's sign. Which equipment should the nurse obtain?
- A. Tongue blade
- B. Blood pressure cuff
- C. Reflex hammer
- D. Stethoscope
Correct Answer: B
Rationale: Trousseau’s sign is elicited by inflating a blood pressure cuff on the arm to induce carpopedal spasm indicating hypocalcemia. The other equipment is not used for this assessment.
Which of the following side effects is associated with androgen therapy?
- A. Gynecomastia
- B. Increased appetite
- C. Virilization
- D. Euphoria
Correct Answer: C
Rationale: Androgen therapy promotes male secondary sexual characteristics leading to virilization (e.g. deepened voice facial hair). Gynecomastia is associated with estrogen and increased appetite or euphoria are not typical side effects of androgens.
A 30-year-old client in the third trimester of her pregnancy asks the nurse for advice about upper respiratory discomforts. She complains of nasal stuffiness and epistaxis, most noticeable on the left side. Which reply by the nurse is correct?
- A. It sounds as though you are coming down with a bad cold. I'll ask the doctor to prescribe a decongestant for relief of symptoms.'
- B. A good vaporizer will help; avoid the cool air kind. Also, try saline nose drops, and spend less time on your left side.'
- C. These discomforts are all a result of increased blood supply; one of the pregnancy hormones, estrogen, causes them.'
- D. This is most unusual. I'm sure your obstetrician will want you to see an ENT (ear, nose, throat) specialist.'
Correct Answer: C
Rationale: Decongestants may exaggerate the nasal stuffiness associated with pregnancy. Judicious use of decongestants and nasal sprays is advocated during pregnancy. Cool air vaporizers and saline drops may help to relieve the nasal stuffiness. Positioning on either lateral side does not decrease nasal stuffiness or prevent epistaxis. Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation, which contributes to epistaxis. The nurse may recommend cool air vaporizers and saline drops to help with the nasal stuffiness. Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation discomforts associated with pregnancy.
The nurse knows that children are more susceptible to respiratory tract infections owing to physiological differences. These childhood differences, adverts an adult, include:
- A. Fewer alveoli, slower respiratory rate
- B. Diaphragmatic breathing, larger volume of air
- C. Larger number of alveoli, diaphragmatic breathing
- D. Rounded shape of chest, smaller volume of air
Correct Answer: D
Rationale: Although a child has fewer alveoli than an adult, the child's respiratory rate is faster. Although a child may use diaphragmatic breathing, the adult exchanges a larger volume of air. The adult has a larger number of alveoli than a child. The child's chest is rounded whereas the adult chest is more of an oval shape, and the child does exchange a smaller volume of air than an adult.
The client is admitted with a diagnosis of gestational hypertension. Which assessment finding requires immediate notification of the physician?
- A. Blood pressure of 140/90
- B. 2+ proteinuria
- C. Headache and visual disturbances
- D. Edema of the hands
Correct Answer: C
Rationale: Headache and visual disturbances in gestational hypertension suggest severe preeclampsia or impending eclampsia requiring immediate physician notification. BP of 140/90 proteinuria and edema are concerning but less urgent unless severe.