Nursing Elites

1. A nurse is caring for a client prescribed enoxaparin for deep vein thrombosis prophylaxis. Which of the following client assessments requires immediate intervention?

• A. Platelet count of 95,000/mm³
• B. Blood pressure of 145/90 mmHg
• C. Heart rate of 95 beats per minute
• D. Pain at the injection site

Correct answer: A

Rationale: A platelet count of 95,000/mm³ requires immediate intervention as it is low and increases the risk of bleeding, which is a potential complication of enoxaparin therapy. Low platelet counts can predispose the patient to hemorrhage, and administering anticoagulants like enoxaparin in such cases can further increase the bleeding risk. Monitoring platelet counts is crucial during anticoagulant therapy to prevent serious bleeding complications. The other options do not pose immediate risks related to enoxaparin therapy. A slightly elevated blood pressure, a heart rate of 95 beats per minute, and pain at the injection site are common findings that may not warrant immediate intervention in this context.

2. A client has been prescribed lisinopril. Which of the following medication interactions should the nurse instruct this client about?

• A. Potassium supplements
• B. Ciprofloxacin
• C. Escitalopram
• D. Magnesium supplements

Correct answer: A

Rationale: The correct answer is A: Potassium supplements. Clients taking lisinopril should avoid potassium supplements and potassium-sparing diuretics due to the risk of hyperkalemia. This interaction can lead to dangerously high levels of potassium in the blood, which can be harmful. Choice B, Ciprofloxacin, is not typically associated with a significant interaction with lisinopril. Choice C, Escitalopram, is an antidepressant and does not have a known significant interaction with lisinopril regarding potassium levels. Choice D, Magnesium supplements, are generally safe to take with lisinopril and do not pose a significant risk of hyperkalemia.

3. A client receiving epoetin alfa therapy for anemia is being monitored for therapeutic effects. Which of the following laboratory values indicates the medication is effective?

• A. White blood cell count
• B. Hematocrit
• C. Platelet count
• D. Red blood cell count

Correct answer: B

Rationale: The correct answer is B: Hematocrit. An increase in hematocrit levels indicates the effectiveness of epoetin alfa in treating anemia. Hematocrit reflects the percentage of red blood cells in the blood, so an increase in hematocrit signifies an improvement in the patient's red blood cell count and oxygen-carrying capacity. Choices A, C, and D are incorrect because white blood cell count, platelet count, and red blood cell count do not directly reflect the therapeutic effects of epoetin alfa in treating anemia.

4. Before administering blood products, which action should be taken?

• A. Assess the client's temperature
• B. Document client response
• C. Prime IV tubing with 0.45% sodium chloride
• D. Administer epinephrine

Correct answer: A

Rationale: Correct answer: Before administering blood products, the client's temperature must be assessed to establish a baseline and monitor for transfusion reactions. Choice B is incorrect because documenting client response should occur after administering the blood products. Choice C is incorrect as priming IV tubing with 0.45% sodium chloride is not directly related to assessing the client before administering blood products. Choice D is incorrect because administering epinephrine is not a routine action before administering blood products.

5. A 45-year-old client is taking methylprednisolone. What pharmacologic action should the nurse expect with this therapy?

• A. Suppression of beta2 receptors
• B. Suppression of airway mucus production
• C. Fortification of bones
• D. Suppression of candidiasis

Correct answer: B

Rationale: The correct answer is B: Suppression of airway mucus production. Corticosteroids like methylprednisolone are known to suppress airway mucus production. This action helps in reducing inflammation and swelling in the airways, making breathing easier for individuals with conditions like asthma or COPD. Choices A, C, and D are incorrect. Suppression of beta2 receptors is more related to beta-blockers, fortification of bones is associated with medications like bisphosphonates, and suppression of candidiasis is not a typical pharmacologic action of methylprednisolone.

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