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What should be monitored to evaluate the effectiveness of enoxaparin in a patient with deep vein thrombosis (DVT)?
- A. Prothrombin time (PT)
- B. Partial thromboplastin time (PTT)
- C. International normalized ratio (INR)
- D. Platelet count
Correct Answer: C
Rationale: Rationale:
1. Enoxaparin is a low molecular weight heparin that primarily affects the intrinsic pathway of coagulation.
2. INR is used to monitor the effectiveness of anticoagulants affecting the intrinsic pathway.
3. Monitoring INR helps ensure the patient is within the therapeutic range to prevent clotting without excessive bleeding.
4. PT and PTT primarily evaluate the extrinsic and intrinsic pathways, respectively, not specific to enoxaparin.
5. Platelet count is not directly related to monitoring the effectiveness of enoxaparin in treating DVT.
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While assessing a client with diabetes mellitus, the nurse observes an absence of hair growth on the client's legs. What additional assessment provides further data to support this finding?
- A. Palpate for the presence of femoral pulses bilaterally.
- B. Assess for the presence of a positive Homan's sign.
- C. Observe the appearance of the skin on the client's legs.
- D. Watch the client's posture and balance during ambulation.
Correct Answer: C
Rationale: The correct answer is C: Observe the appearance of the skin on the client's legs. In clients with diabetes mellitus, poor circulation can lead to decreased hair growth on the legs. By observing the skin appearance, the nurse can look for signs of poor circulation such as dry skin, thinning of the skin, or discoloration. This assessment provides further data to support the finding of absent hair growth.
Choices A, B, and D are incorrect because they do not directly relate to the assessment of absent hair growth in clients with diabetes mellitus. Palpating for femoral pulses assesses circulation but does not specifically address the absence of hair growth. Assessing for Homan's sign evaluates for deep vein thrombosis, which is not directly related to hair growth. Watching posture and balance during ambulation assesses mobility and stability but does not provide information on hair growth or circulation in the legs.
A patient with atrial fibrillation is prescribed warfarin. Which laboratory test should the nurse monitor to assess the effectiveness of the medication?
- A. Complete blood count (CBC)
- B. Prothrombin time (PT)/INR
- C. Partial thromboplastin time (PTT)
- D. Serum potassium level
Correct Answer: B
Rationale: The correct answer is B: Prothrombin time (PT)/INR. This is because warfarin is a medication that affects the clotting ability of the blood by inhibiting vitamin K-dependent clotting factors. PT/INR is the specific laboratory test used to monitor the effectiveness of warfarin therapy. PT measures how long it takes for blood to clot, while INR standardizes the PT results. Monitoring PT/INR helps to ensure that the patient is within the target therapeutic range for anticoagulation.
Incorrect choices:
A: Complete blood count (CBC) - CBC does not directly assess the effectiveness of warfarin therapy.
C: Partial thromboplastin time (PTT) - PTT is used to monitor the effectiveness of heparin therapy, not warfarin.
D: Serum potassium level - Monitoring serum potassium level is not directly related to assessing the effectiveness of warfarin therapy.
A client is being discharged with a new prescription for enoxaparin (Lovenox). Which instruction should the nurse include?
- A. Administer the injection in your thigh.
- B. Do not expel the air bubble from the syringe before injection.
- C. Massage the injection site after administration.
- D. Alternate the injection site between the arms.
Correct Answer: B
Rationale: The correct answer is B because expelling the air bubble from the syringe before injection helps ensure accurate dosage delivery and prevents air from being injected into the patient. Administering the injection in the thigh (A) is incorrect as enoxaparin is typically given in the abdomen. Massaging the injection site (C) can cause bruising or hematoma formation. Alternating injection sites between arms (D) is not relevant as enoxaparin is usually given in the abdomen.
A patient with type 1 diabetes is prescribed insulin glargine. What is the primary characteristic of this insulin?
- A. Rapid-acting
- B. Intermediate-acting
- C. Long-acting
- D. Short-acting
Correct Answer: C
Rationale: Insulin glargine is a long-acting insulin due to its slow and consistent release, providing basal insulin coverage for about 24 hours. This steady release mimics the body's natural basal insulin secretion pattern. Rapid-acting insulins (A) work quickly to control postprandial glucose levels. Intermediate-acting insulins (B) have a slower onset and last for a moderate duration. Short-acting insulins (D) act quickly but have a shorter duration of action compared to long-acting insulins.
When assessing a male client who is receiving a unit of packed red blood cells (PRBCs), the nurse notes that the infusion was started 30 minutes ago, and 50 ml of blood is left to be infused. The client's vital signs are within normal limits. He reports feeling 'out of breath' but denies any other complaints. What action should the nurse take at this time?
- A. Administer a PRN prescription for diphenhydramine (Benadryl).
- B. Start the normal saline attached to the Y-tubing at the same rate.
- C. Decrease the intravenous flow rate of the PRBC transfusion.
- D. Ask the respiratory therapist to administer PRN albuterol (Ventolin).
Correct Answer: C
Rationale: The correct action for the nurse to take in this situation is to decrease the intravenous flow rate of the PRBC transfusion. The client is showing early signs of a transfusion reaction, as evidenced by feeling 'out of breath'. By decreasing the flow rate of the transfusion, the nurse can slow down the rate at which the remaining blood is infused, potentially preventing a more severe reaction. Administering diphenhydramine or albuterol would not address the underlying issue of a potential transfusion reaction. Starting normal saline at the same rate may exacerbate the client's symptoms and is not indicated in this scenario.