Nursing Elites

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

• A. Gently rub the injection site after removing the needle
• B. Have the client maintain a side-lying position for at least five minutes
• C. Remove the needle and engage the needle safety device
• D. Apply heat to the injection site

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 Rubbing the injection site after the needle is withdrawn is not recommended as it may cause irritation and bruising.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. The nurse is checking laboratory values on a patient who has crackling rales in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which of the following laboratory values does the nurse expect to be abnormal?

• A. Potassium.
• B. B-type natriuretic peptide (BNP).
• C. C-reactive protein (CRP).
• D. Platelets.

Correct answer: B

Rationale: The client's symptoms suggest heart failure. BNP is a neurohormone released from the ventricles due to increased pressure and stretch, as seen in heart failure. A BNP level greater than 51 pg/mL is often associated with mild heart failure, with higher levels indicating more severe heart failure. Potassium levels are not typically affected by heart failure. CRP is an inflammation indicator used to predict coronary artery disease risk, not directly related to heart failure in this case. The client's symptoms do not suggest bleeding or clotting abnormalities associated with platelet count issues, making platelets an unlikely abnormal value.

3. The client is wheezing and struggling to breathe. Which of the inhaled medications is indicated at this time?

• A. Fluticasone (Flovent)
• B. Salmeterol (Serevent)
• C. Theophylline (Theodur)
• D. Albuterol (Atrovent)

Correct answer: D

Rationale: The correct answer is Albuterol (Atrovent) because it is a rapid-acting bronchodilator, essential for a client experiencing wheezing and difficulty breathing. Albuterol acts quickly, dilating the airways and providing immediate relief in cases of respiratory distress. Fluticasone (Flovent) and Salmeterol (Serevent) are maintenance medications for long-term asthma control, not suitable for acute situations described. Theophylline (Theodur) is a bronchodilator but with a slower onset compared to Albuterol, making it less appropriate for a client in immediate distress.

4. Which of the following can certain foods like broccoli, oranges, dark greens, and dark yellow vegetables help improve?

• A. Vitamin intake
• B. Body functions
• C. Defense mechanisms
• D. Disease cure

Correct answer: C

Rationale: Certain foods like broccoli, oranges, dark greens, and dark yellow vegetables can help improve defense mechanisms by enhancing the immune system and overall health. While these foods can boost defense mechanisms, they are not a cure for diseases, do not balance body functions, and are not intended to solely supplement vitamin intake, which may be necessary in some cases. Therefore, the correct answer is defense mechanisms as these foods strengthen the body's ability to fight off illnesses and maintain health.

5. The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical manifestation would indicate that the client should not be advanced to the next level?

• A. Facial flushing
• B. A complaint of chest heaviness
• C. Heart rate increase of 10 beats/min
• D. Systolic blood pressure increase of 10 mm Hg

Correct answer: B

Rationale: The correct answer is a complaint of chest heaviness. Onset of chest pain indicates myocardial ischemia, which can be life-threatening. Chest pain in a client post-myocardial infarction should be promptly evaluated, and the activity level should not be advanced. Choices A, C, and D are not the best options because facial flushing, a heart rate increase of 10 beats/min, and a systolic blood pressure increase of 10 mm Hg are not typical indicators of myocardial ischemia or necessarily contraindications for advancing activity levels in this context.

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