Nursing Elites

1. A nurse is teaching a client how to administer enoxaparin. Which of the following instructions should the nurse include?

• A. Inject the medication into the muscle of the thigh
• B. Massage the injection site after administration
• C. Pinch the skin before injecting
• D. Administer the medication at the same time each day

Correct answer: C

Rationale: The correct instruction for administering enoxaparin is to pinch the skin before injecting. Pinching the skin helps create a proper fold for subcutaneous injections like enoxaparin, ensuring proper delivery of the medication into the subcutaneous tissue. Choice A is incorrect because enoxaparin should be administered subcutaneously, not into the muscle. Injecting it into the muscle can lead to complications. Choice B is incorrect because massaging the injection site after administration can increase the risk of bleeding or bruising due to the anticoagulant properties of enoxaparin. Choice D is incorrect as it is a general instruction and does not specifically relate to the administration of enoxaparin.

2. What are the early signs of DVT?

• A. Leg pain, swelling, and redness
• B. Shortness of breath and high fever
• C. Cough and chest pain
• D. Decreased oxygen saturation and low blood pressure

Correct answer: A

Rationale: The correct answer is A: Leg pain, swelling, and redness are early signs of DVT. DVT (Deep Vein Thrombosis) is a condition where blood clots form in deep veins, commonly in the legs. These clots can cause symptoms like pain, swelling, and redness in the affected leg. Choices B, C, and D describe symptoms more commonly associated with other conditions like pulmonary embolism (shortness of breath and high fever), respiratory issues (cough and chest pain), and cardiovascular problems (decreased oxygen saturation and low blood pressure), respectively. Therefore, they are not indicative of early signs of DVT.

3. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client?

• A. Total bilirubin.
• B. Urine ketones.
• C. Serum potassium.
• D. Platelet count.

Correct answer: C

Rationale: The correct answer is C: Serum potassium. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium. Therefore, the nurse should monitor the client's serum potassium levels to prevent hyperkalemia, which can be a potential side effect of spironolactone. Monitoring total bilirubin levels (A) is not specifically required for clients taking spironolactone. Urine ketones (B) are not directly influenced by spironolactone use. Platelet count (D) is not typically monitored in clients taking spironolactone.

4. A nurse is reinforcing teaching about home care for conjunctivitis with the parent of a school-age child. Which of the following information should the nurse include?

• A. Use a separate washcloth for the child
• B. Apply cold compresses to the eyes
• C. Apply warm compresses to the eyes
• D. Keep the child home until symptoms have resolved

Correct answer: A

Rationale: The correct answer is to use a separate washcloth for the child. This is important to prevent the spread of infection when a child has conjunctivitis. Using the same washcloth can lead to cross-contamination and further spread of the condition. Applying cold or warm compresses may provide comfort but do not address the prevention of spreading the infection. Keeping the child home until symptoms have resolved may be necessary, but the primary focus should be on preventing the spread of the infection within the household.

5. A client who had a vaginal delivery 4 hours ago has a fourth-degree perineal laceration. Which of the following interventions should the nurse recommend?

• A. Encourage ambulation
• B. Apply ice packs
• C. Restrict the client's fluid intake
• D. Administer stool softeners

Correct answer: B

Rationale: Correct Answer: Applying ice packs is the most appropriate intervention for a client with a fourth-degree perineal laceration. Ice packs help reduce swelling and promote comfort, aiding in the healing process. Choice A, encouraging ambulation, may not be suitable immediately after a fourth-degree laceration due to the need for rest and proper wound care. Choice C, restricting fluid intake, is not indicated and can lead to dehydration, which is not beneficial for wound healing. Choice D, administering stool softeners, may be necessary to prevent constipation and straining, but it is not the priority intervention at this time.

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