The nurse has reviewed the Nurses' Notes, Diagnostic Results, and Laboratory Results.
Enoxaparin 80 mg subcutaneous twice a
Potassium chloride 20 mEq PO twice a day
Ciprofloxacin 750 mg PO twice a day
Enalapril 5 mg PO daily
Rosuvastatin 20 mg PO daily
Digoxin 0.25 mg PO daily
Metformin 850 mg PO daily
Albuterol 2 puffs every 4 to 6 hr as needed
Correct Answer : B,D,E,G
Rationale:
A. Enoxaparin 80 mg subcutaneous twice a day: Enoxaparin is an anticoagulant used for prevention or treatment of thromboembolic events. There is no indication from the client’s current labs, vitals, or diagnostics (D-dimer within normal limits, no evidence of clot) to initiate anticoagulation at this time.
B. Potassium chloride 20 mEq PO twice a day: The client’s potassium level is 3.6 mEq/L, which is at the lower end of the normal range. Supplementation may be warranted, particularly if antihypertensive therapy such as a diuretic is initiated, to prevent hypokalemia and maintain cardiac stability.
C. Ciprofloxacin 750 mg PO twice a day: There is no evidence of bacterial infection in the client’s assessment, labs, or diagnostics. Prescribing an antibiotic is unnecessary and not indicated.
D. Enalapril 5 mg PO daily: The client’s blood pressure is 164/92 mm Hg, which is hypertensive. Enalapril, an ACE inhibitor, is appropriate to manage hypertension, reduce cardiovascular risk, and potentially improve renal outcomes given the family history of renal failure.
E. Rosuvastatin 20 mg PO daily: The client has significantly elevated cholesterol (total cholesterol 280 mg/dL, LDL 220 mg/dL, HDL 20 mg/dL) and triglycerides 220 mg/dL. Initiating a statin is appropriate to reduce cardiovascular risk and manage hyperlipidemia.
F. Digoxin 0.25 mg PO daily: The client does not exhibit heart failure symptoms or arrhythmias that require digoxin at this time. ECG shows only sinus tachycardia without S-T changes, so digoxin is not indicated.
G. Metformin 850 mg PO daily: The client’s glucose is 310 mg/dL and HbA1c is 7%, indicating diabetes mellitus. Initiating metformin is appropriate for glycemic control and to reduce the risk of complications associated with hyperglycemia.
H. Albuterol 2 puffs every 4 to 6 hr as needed: The client’s lungs are clear on auscultation, and there is no active respiratory distress. Albuterol is not indicated for ongoing therapy in this assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Instruct the client to discard the medication in the toilet: Disposing of medication in the toilet is not a recommended first action, as it does not address the client’s question about safely taking a half dose. Safe disposal is only necessary for expired or unwanted medications.
B. Manually break the tablets in half: Manually breaking tablets without knowing if they are designed to be split can lead to inaccurate dosing and affect drug efficacy. Some medications are not safe to split due to extended-release properties or uneven distribution of active ingredients.
C. Determine if the tablets are scored: Scored tablets are specifically designed to be split, ensuring accurate dosing. The nurse should verify whether the medication is scored before advising the client to cut it, ensuring safety and effectiveness of the prescribed dose.
D. Ask the pharmacy to create a liquid version of the medication: While a liquid formulation may be appropriate for accurate dosing if the tablet cannot be safely split, the first step is to confirm whether the current tablet can be divided. The pharmacy can then provide alternatives if splitting is unsafe.
Correct Answer is A
Explanation
Rationale:
A. Provide the client with a stool softener: Clients with thrombocytopenia are at increased risk for bleeding, including gastrointestinal bleeding. Hard stools can cause straining during defecation, which may lead to rectal bleeding. Administering a stool softener helps prevent constipation and reduces the risk of bleeding from the gastrointestinal tract.
B. Remove fresh flowers from the client's room: This intervention is appropriate for clients who are immunocompromised to prevent infection, but it is not specifically necessary for thrombocytopenia unless the client also has neutropenia. The main concern in thrombocytopenia is bleeding, not infection.
C. Avoid serving the client raw vegetables: While raw vegetables may carry a risk of infection, thrombocytopenia alone does not require dietary restrictions for raw vegetables. Safe food handling is important, but preventing bleeding is the primary focus of care.
D. Encourage the client to floss daily: Flossing can increase the risk of gum bleeding in clients with thrombocytopenia. Oral hygiene should be maintained gently with soft-bristled toothbrushes, but daily flossing is not recommended because it may cause unnecessary bleeding.
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