A nurse is reinforcing postoperative teaching with a client who has a prescription for enoxaparin to prevent deep vein thrombosis. Which of the following information should the nurse include in the teaching as a potential adverse effect of this medication?

Ringing in the ears

Black, tarry stools

Fine hand tremors

Diarrhea

Answer and Explanation

The Correct Answer is B

A. Ringing in the ears: Ringing in the ears (tinnitus) is not a common adverse effect of enoxaparin. It is typically associated with medications like aspirin or other salicylates, not low-molecular-weight heparins like enoxaparin.

B. Black, tarry stools: Black, tarry stools are a sign of gastrointestinal bleeding, which is a serious potential adverse effect of anticoagulant medications like enoxaparin. Clients taking enoxaparin should be instructed to report this symptom immediately, as it could indicate internal bleeding.

C. Fine hand tremors: Fine hand tremors are not a known adverse effect of enoxaparin. They are more commonly associated with other medications, such as certain psychiatric drugs or neurologic conditions.

D. Diarrhea: Diarrhea is not a common adverse effect of enoxaparin. While gastrointestinal symptoms can occur with many medications, it is not a primary concern or indication for discontinuing enoxaparin.

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Correct Answer is B

Explanation

A. Contact the provider within 48 hr to obtain a prescription for the restraints: A provider’s order for restraints must be obtained immediately or within a very short time frame, usually within 1 hour, depending on facility policy. Waiting 48 hours would be inappropriate and could lead to violation of patient rights.

B. Remove the restraints from the client's wrists every 2 hr: Restraints must be removed at least every 2 hours to assess skin integrity, provide range of motion exercises, and evaluate the continued need for restraints. This practice ensures client safety, prevents complications such as pressure injuries, and respects client dignity.

C. Check that one finger will fit between the client's wrists and the restraints: The correct practice is to ensure that two fingers can fit between the restraint and the skin to prevent circulatory impairment and skin breakdown. One finger would be too tight and could increase the risk of injury.

D. Fasten the restraints' ties to the bed's side rails: Restraints should always be tied to the bed frame, not the side rails. Attaching restraints to movable parts like side rails can cause injury if the rail is lowered or repositioned, leading to unnecessary strain or trauma to the client.

A. Apply the gown before the gloves. B. The gown with the gloves on C. Tuck the glove cuffs under the gown sleeves. D. Push the gowns sleeves up to the elbows

Correct Answer is A

Explanation

A. Apply the gown before the gloves: The gown must be applied before donning gloves to ensure that the gown fully covers the arms and torso, providing a protective barrier against contamination. Gloves are then pulled over the gown cuffs to maintain a proper seal and reduce the risk of pathogen exposure, especially with infections like Clostridium difficile.

B. The gown with the gloves on: Wearing the gown after gloves compromises the sterile barrier, allowing pathogens to contact the skin or clothing. This technique increases the risk of contamination because the gloves may not completely cover or seal the gown’s cuffs properly, which is critical in preventing the spread of infection.

C. Tuck the glove cuffs under the gown sleeves: Gloves should not be tucked under gown sleeves. Instead, gloves should cover the gown cuffs, creating a continuous protective layer. Tucking gloves under the gown can leave the wrists exposed and vulnerable to contamination, particularly when caring for clients with highly transmissible infections.

D. Push the gown sleeves up to the elbows: Pushing the sleeves up to the elbows defeats the protective purpose of the gown. It exposes the forearms to potential pathogens and bodily fluids, increasing the risk of infection transmission to both the nurse and other clients, especially when dealing with spore-forming bacteria like Clostridium difficile.

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A nurse is reinforcing postoperative teaching with a client who has a prescription for enoxaparin to prevent deep vein thrombosis. Which of the following information should the nurse include in the teaching as a potential adverse effect of this medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is confused and is trying to pull out their IV catheter. After attempting other measures to prevent the client from self-harm, the nurse places wrist restraints on the client. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has Clostridium difficile. When applying a cover gown, which of the following techniques should the nurse use?

Correct Answer is A

Explanation

A nurse in a health clinic is assisting in the care of a client diagnosed with chlamydia. The client was prescribed azithromycin 1 g PO once. Which of following allergy findings in the client's history should the nurse report to the provider?

A nurse is working with a client who becomes combative and threatens other clients and staff. Which of the following actions should the nurse take?

A nurse is collecting data from a client who has left-sided heart failure. Which of the following findings should the nurse expect?

A nurse is reinforcing teaching with a client who is beginning menopause. Which of the following statements by the client indicates an understanding of the teaching?

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A charge nurse is educating a newly licensed nurse on how to perform a sterile dressing change on a client. Which of the following action indicates an understanding of the teaching?

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