Nokea
Which of the following actions by a nurse who is administering fondaparinux to a patient with venous thromboembolism (VTE) indicates that more education about the medication is needed?
- A. The nurse avoids rubbing the injection site after giving the medication.
- B. The nurse injects the medication into the abdominal subcutaneous tissue.
- C. The nurse fails to assess the partial thromboplastin time (PTT) before administration of the medication.
- D. The nurse ejects the air bubble in the syringe before administering the medication.
Correct Answer: D
Rationale: The air bubble is not ejected before giving fondaparinux. The other actions by the nurse are appropriate.
You may also like to solve these questions
A patient with a venous thromboembolism (VTE) is started on enoxaparin and warfarin. The patient asks the nurse why two medications are necessary. Which of the following responses by the nurse is accurate?
- A. Administration of two anticoagulants reduces the risk for recurrent venous thrombosis.
- B. Enoxaparin will start to dissolve the clot, and warfarin will prevent any more clots from occurring.
- C. The enoxaparin will work immediately, but the warfarin takes several days to have an effect on coagulation.
- D. Because of the potential for a pulmonary embolism, it is important for you to have more than one anticoagulant.
Correct Answer: C
Rationale: Low-molecular-weight heparin (LMWH) such as enoxaparin has an immediate effect on coagulation and is used until warfarin reaches therapeutic levels, which takes several days.
Several hours after an open surgical repair of an abdominal aortic aneurysm, the patient develops a urinary output of 20 mL/hour for 2 hours. Which of the following prescriptions should the nurse anticipate?
- A. An additional antibiotic
- B. White blood cell (WBC) count
- C. Decrease in IV infusion rate
- D. Blood urea nitrogen (BUN) level
Correct Answer: D
Rationale: The decreased urine output suggests decreased renal perfusion, and monitoring of renal function is needed. There is no indication that infection is a concern, so antibiotic therapy and a WBC count are not needed. The IV rate may be increased because hypovolemia may be contributing to the patient's decreased urinary output.
The nurse is assessing a patient in the emergency department with a history of an abdominal aortic aneurysm with severe back pain and absent pedal pulses. Which of the following actions should the nurse take first?
- A. Obtain the blood pressure.
- B. Ask the patient about tobacco use.
- C. Draw blood for ordered laboratory testing.
- D. Assess for the presence of an abdominal bruit.
Correct Answer: A
Rationale: Since the patient appears to be experiencing aortic dissection, the nurse's first action should be to determine the hemodynamic status by assessing blood pressure. The other actions also may be done, but they will not provide information that will determine what interventions are needed immediately for this patient.
The nurse is assessing a patient with possible peripheral artery disease (PAD) and obtains a brachial BP of 140/80 and an ankle pressure of 110/70. The nurse calculates the patient's ankle-brachial index (ABI) as
Correct Answer: 0.78 or 0.79
Rationale: The ABI is calculated by dividing the ankle systolic BP by the brachial systolic BP (110/140 â?? 0.78 or 0.79).
Which of the following patients in the emergency department should the nurse assess first?
- A. 62-year-old who has gangrenous ulcers on both feet
- B. 50-year-old who is complaining of 'tearing' chest pain.
- C. 45-year-old who is taking anticoagulants and has bloody stools
- D. 36-year-old who has right calf tenderness, redness, and swelling
Correct Answer: B
Rationale: The patient's presentation is consistent with aortic dissection, which will require rapid intervention. The other patients do not need urgent interventions.