A nurse is completing discharge teaching with a client who has a new prescription for enoxaparin to treat unstable angina. Which of the following instructions should the nurse include in the teaching?

"Administer this medication into your leg muscle.".

"Expel the excess air in the syringe before you administer the medication.".

"Insert the entire needle into your skin to administer medication completely.".

"Take ibuprofen for fever following administration of this medication.".

Answer and Explanation

The Correct Answer is C

Answer: C. "Insert the entire needle into your skin to administer medication completely."

Rationale:

A) "Administer this medication into your leg muscle."
Enoxaparin should be administered subcutaneously, typically in the abdominal area, not into a muscle. Injecting it intramuscularly can lead to unpredictable absorption and increase the risk of bleeding.

B) "Expel the excess air in the syringe before you administer the medication."
This statement is incorrect. For enoxaparin, it is recommended to retain the air bubble in the syringe. The air bubble helps ensure the entire dose is delivered and minimizes leakage at the injection site.

C) "Insert the entire needle into your skin to administer medication completely."
This is an appropriate instruction as it emphasizes the need to fully insert the needle for effective subcutaneous delivery of enoxaparin. Proper technique is essential to ensure the medication is administered as intended.

D) "Take ibuprofen for fever following administration of this medication."
This recommendation is not advisable because ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), can increase the risk of bleeding, especially when taken concurrently with enoxaparin. The client should consult their healthcare provider for safe alternatives for managing fever or pain.

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Correct Answer is B

Explanation

Choice A rationale:

Hemoptysis, which is the coughing up of blood, is not typically associated with a urinary tract infection (UTI). It is more commonly related to respiratory or pulmonary issues.

Choice B rationale:

Hematuria, the presence of blood in the urine, is a common finding in a UTI. Inflammation and infection in the urinary tract can lead to the presence of blood cells in the urine.

Choice C rationale:

Hyperglycemia, an elevated blood glucose level, is not directly related to a UTI. It may be seen in individuals with diabetes, but it is not a typical finding in a UTI.

Choice D rationale:

Hypocalcemia, a low level of calcium in the blood, is not a characteristic finding in a UTI. UTIs primarily affect the urinary system and do not directly involve calcium metabolism.

A. Administer the medication no faster than 100 mg/min. B. Monitor plasma phenytoin levels to establish the therapeutic range. C. Add the medication to the existing IV solution. D. Monitor the client for hypertension.

Correct Answer is A

Explanation

Choice A rationale:

Administering phenytoin IV no faster than 100 mg/min is crucial to prevent adverse effects such as cardiovascular collapse or severe hypotension. Rapid administration of phenytoin can cause cardiac arrhythmias and should be avoided.

Choice B rationale:

Monitoring plasma phenytoin levels to establish the therapeutic range is a necessary action in managing the client's seizure disorder, but it does not pertain to the specific administration of phenytoin via intermittent bolus.

Choice C rationale:

Adding the medication to the existing IV solution is not appropriate for phenytoin administration. Phenytoin should be administered separately and not mixed with other IV solutions to maintain its stability and prevent interactions.

Choice D rationale:

Monitoring the client for hypertension is not directly related to the administration of phenytoin via intermittent bolus. Hypertension is not a common adverse effect of this medication. However, blood pressure should be monitored as part of routine care for any client on antiepileptic therapy.

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A nurse is completing discharge teaching with a client who has a new prescription for enoxaparin to treat unstable angina. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who has developed a UTI. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is planning to administer phenytoin IV via intermittent bolus to a client who has a seizure disorder and is receiving a continuous IV infusion of dextrose 5% in water (D5W). Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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A nurse is completing discharge teaching with a client who has a new prescription for enoxaparin to treat unstable angina. Which of the following instructions should the nurse include in the teaching?