a nurse is caring for a client who has a new prescription for enoxaparin which of the following actions should the nurse take
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Nursing Elites

ATI RN

ATI Exit Exam 2024

1. A healthcare provider is caring for a client who has a new prescription for enoxaparin. Which of the following actions should the healthcare provider take?

Correct answer: B

Rationale: The correct answer is to inject the medication into the client's abdomen. Enoxaparin is a medication that should be administered subcutaneously into the abdomen to ensure proper absorption. Choice A is incorrect because enoxaparin should not be administered intramuscularly. Choice C is incorrect because massaging the injection site after administration is not recommended for enoxaparin injections. Choice D is incorrect because aspirating for blood return is not necessary before administering a subcutaneous injection like enoxaparin.

2. A nurse is assessing a client with a history of post-traumatic stress disorder (PTSD). Which of the following findings should the nurse expect?

Correct answer: B

Rationale: The correct answer is B: Loss of interest in usual activities. Clients with PTSD often exhibit symptoms such as numbing, which can manifest as a loss of interest in activities they once enjoyed. Choice A, dependence on family and friends, is more indicative of seeking support rather than a direct symptom of PTSD. Choice C, ritualistic behavior, is more commonly associated with conditions like obsessive-compulsive disorder. Choice D, passive-aggressive behavior, is not a typical finding in clients with PTSD.

3. A healthcare provider is teaching a client who has a new prescription for levothyroxine. Which of the following instructions should the healthcare provider include?

Correct answer: B

Rationale: The correct instruction for a client prescribed levothyroxine is to take the medication at the same time every day. This consistency is important for maintaining stable thyroid hormone levels. Choice A is incorrect because levothyroxine should be taken on an empty stomach to ensure proper absorption. Choice C is important but not directly related to the administration of levothyroxine. Choice D is incorrect as antacids can interfere with the absorption of levothyroxine.

4. A nurse is reviewing the medical record of a client who is 24 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: The correct answer is C. A temperature of 38.6°C (101.5°F) is above the normal range and indicates a fever, which is a concerning finding postoperatively. Fever can be a sign of infection, so the nurse should report this finding to the provider for further evaluation and intervention. Choices A, B, and D are within expected parameters for a client who is 24 hours postoperative following abdominal surgery and do not require immediate reporting. A heart rate of 90/min, serosanguineous drainage in the surgical drain, and a urinary output of 60 mL/hr are all common postoperative findings that do not raise immediate concerns.

5. How should fluid balance be assessed in a patient with heart failure?

Correct answer: A

Rationale: In patients with heart failure, monitoring daily weight is the most accurate method for assessing fluid balance. Weight gain can indicate fluid retention, a common issue in heart failure patients. Monitoring input and output (B) is essential but may not always accurately reflect fluid balance. Checking for edema (C) is important as it can indicate fluid accumulation, but daily weight monitoring is more precise. Monitoring blood pressure (D) is important in heart failure management but does not directly assess fluid balance.

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