after injecting enoxaparin lovenox subcutaneously into the abdomen which action should the nurse take
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Nursing Elites

NCLEX-PN

Kaplan NCLEX Question of The Day

1. After administering enoxaparin (Lovenox) subcutaneously into the abdomen, which action should the nurse take?

Correct answer: C

Rationale: After administering a subcutaneous injection of enoxaparin (Lovenox) into the abdomen, the nurse should remove the needle and engage the needle safety device. Rubbing the injection site after the needle is withdrawn is not recommended as it may cause irritation and bruising. Having the client maintain a side-lying position for at least five minutes is unnecessary for a subcutaneous injection into the abdomen. Applying heat to the injection site is not indicated after administering enoxaparin subcutaneously; it could increase the risk of bleeding or bruising at the injection site.

2. A young female teenager describes a brutal assault and rape to the nurse on duty. Which of the following actions should the nurse take first?

Correct answer: B

Rationale: In a situation where a patient describes a brutal assault and rape, the first priority should be to provide emotional support and create a safe and supportive environment. This helps the patient feel secure and cared for, which is crucial for their well-being at that moment. Checking with the case manager about police intervention should come after ensuring the patient's immediate emotional needs are addressed. Cleaning the patient's wounds, though important, can be secondary to providing emotional stabilization. Referring the patient to a counselor specializing in trauma is also crucial for long-term support, but the immediate focus should be on providing emotional support and stability.

3. A nurse is caring for her clients when her new admit arrives on the unit. What action by the nurse is most appropriate?

Correct answer: C

Rationale: The most appropriate action for the nurse in this situation is to ask the graduate nurse on the floor to initiate the assessment process until she can arrive. Nursing assistants are not qualified to perform assessments, and the unit secretary's role does not involve client assessments. Delegating the assessment to the graduate nurse ensures that a qualified healthcare professional is evaluating the new admission, aligning with the nurse's responsibilities and providing appropriate care.

4. Teaching about the need to avoid foods high in potassium is most important for which client?

Correct answer: D

Rationale: Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. High potassium levels can further burden the kidneys and worsen the condition. Choices A, B, and C are incorrect because clients receiving diuretic therapy, with an ileostomy, or with metabolic alkalosis are at risk for hypokalemia, which is low potassium levels. Therefore, these clients should actually be encouraged to eat foods high in potassium to maintain adequate levels and prevent complications associated with hypokalemia.

5. A patient has been ordered to receive Klonopin for the first time. Which of the following side effects is not associated with Klonopin?

Correct answer: D

Rationale: The correct answer is 'Diplopia.' While drowsiness, ataxia, and salivation elevation are common side effects associated with Klonopin, diplopia is not typically linked to this medication. Diplopia, or double vision, is not a common side effect reported with the use of Klonopin. It is important to monitor patients for the known side effects such as drowsiness, ataxia, and salivation elevation when administering Klonopin. Choice A, B, and C are incorrect as they are known side effects of Klonopin, unlike diplopia which is not commonly observed with this medication.

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