Nokea
The nurse is preparing to administer subcutaneous Lovenox, a low molecular weight heparin. Which intervention should the nurse implement?
- A. Monitor the client’s serum aPTT.
- B. Encourage oral and intravenous fluids.
- C. Do not eat foods high in vitamin K.
- D. Administer in the anterolateral upper abdomen.
Correct Answer: D
Rationale: Lovenox is administered in the anterolateral abdomen for optimal absorption. aPTT is for unfractionated heparin, fluids are unrelated, and vitamin K affects warfarin.
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The nurse is caring for the following clients. After receiving the shift report, which client should the nurse assess first?
- A. The client with a total knee replacement who is complaining of a cold foot.
- B. The client diagnosed with osteoarthritis who is complaining of stiff joints.
- C. The client who needs to receive a scheduled intravenous antibiotic.
- D. The client diagnosed with back pain who is scheduled for a lumbar myelogram.
Correct Answer: A
Rationale: A cold foot post-knee replacement suggests vascular compromise, requiring urgent assessment to prevent tissue damage. Stiff joints, antibiotics, and myelogram prep are lower priority.
Which assessment finding is the best indication that the client is experiencing secondary complications from the fractured ribs?
- A. Irregular pulse rate
- B. The client's affected leg is shorter than her unaffected leg.
- C. The client's affected leg is shorter than her unaffected leg.
- D. The client's affected leg is executed leg is externally rotated.
- E. The client prefers to sit rather than lie flat.
Correct Answer: E
Rationale: Fractured ribs can cause complications like pneumothorax or hemothorax, leading to difficulty breathing when lying flat. The client's preference to sit upright suggests respiratory distress, a secondary complication. Leg findings are unrelated to rib fractures, and irregular pulse is less specific.
The nurse is providing discharge teaching to the 12-year-old with a fractured humerus and the parents. Which information should the nurse include regarding cast care?
- A. Keep the fractured arm at heart level.
- B. Use a wire hanger to scratch inside the cast.
- C. Apply an ice pack to any itching area.
- D. Explain foul smells are expected occurrences.
Correct Answer: A
Rationale: Keeping the arm at heart level reduces edema in a casted humerus. Wire hangers risk skin damage, ice is for swelling not itching, and foul smells indicate infection.
The 35-year-old client who sustained a crushing injury to the left hand and forearm is being discharged. Which referral should the nurse implement?
- A. Refer the client to physical therapy at home.
- B. Refer the client to an assistive living facility.
- C. Refer the client to a workforce commission for job training.
- D. Refer the client to the dietitian.
Correct Answer: A
Rationale: Home PT restores hand/forearm function post-crushing injury. Assisted living, job training, and dietitian referrals are premature or unrelated.
The client newly diagnosed with osteoporosis is prescribed calcitonin by nasal spray. Which assessment data indicate to the nurse an adverse effect of the medication?
- A. The client complains of nausea and vomiting.
- B. The client is drinking two (2) glasses of milk a day.
- C. The client has a runny nose and nasal itching.
- D. The client has had numerous episodes of nosebleeds.
Correct Answer: C
Rationale: Runny nose and nasal itching are common adverse effects of nasal calcitonin. Nausea is less common, milk intake is unrelated, and nosebleeds are not typical.