To prevent deep vein thromboses following knee replacement surgery, an adult male client is receiving daily subcutaneous enoxaparin. Which laboratory result requires immediate action by the nurse?

Reference Range:
Hematocrit [42% to 52% (0.42 to 0.52 volume fraction)]
Platelets [150,000 to 400,000/mm² (150 to 400 × 10^9/L)]
Creatinine [0.5 to 1.1 mg/dL (44 to 97 μmol/L)]
Blood Urea Nitrogen (BUN) [10 to 20 mg/dL (3.6 to 7.1 mmol/L)]

Platelet count of 100,000/mm³ (100 x 10^9/L).

Hematocrit 45% (0.45 volume fraction).

Blood urea nitrogen (BUN) 20 mg/dL (7.1 mmol/L).

Serum creatinine 1.0 mg/dL (88.4 μmol/L).

Answer and Explanation

The Correct Answer is A

Choice A reason: Platelet count of 100,000/mm³ (100 x 10^9/L) is below the normal range and indicates thrombocytopenia, which is a decrease in the number of platelets in the blood. Thrombocytopenia can increase the risk of bleeding and bruising, and can be a serious adverse effect of enoxaparin. This laboratory result requires immediate action by the nurse, such as notifying the prescriber, monitoring for signs of bleeding, and withholding the next dose of enoxaparin.

Choice B reason: Hematocrit 45% (0.45 volume fraction) is within the normal range and does not indicate any problem with the client's red blood cells or oxygen-carrying capacity.

Choice C reason: Blood urea nitrogen (BUN) 20 mg/dL (7.1 mmol/L) is within the normal range and does not indicate any problem with the client's kidney function or hydration status.

Choice D reason: Serum creatinine 1.0 mg/dL (88.4 μmol/L) is within the normal range and does not indicate any problem with the client's kidney function or muscle metabolism.

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Free Nursing Study Resources

Correct Answer is []

Explanation

Body System: Respiratory

The correct choice is A

Choice A: Assess lung sounds This is the correct choice because the client may have developed an allergic reaction to vancomycin, which can cause bronchospasm and wheezing. Assessing lung sounds can help the nurse monitor the client’s respiratory status and intervene if needed.

Choice B: Provide a calm environment This is not the correct choice because providing a calm environment is not specific to the respiratory system. It may help the client feel more comfortable, but it does not address the potential respiratory complications of an allergic reaction.

Choice C: Pain medication This is not the correct choice because pain medication is not related to the respiratory system. The client did not report any pain, and pain medication may have adverse effects on the respiratory system, such as respiratory depression.

Choice D: Chest x-ray This is not the correct choice because a chest x-ray is not indicated for the client at this time. A chest x-ray is a diagnostic test that can show abnormalities in the lungs, such as pneumonia or pleural effusion. However, the client’s symptoms are more likely caused by an allergic reaction, which would not be visible on a chest x-ray.

Body System: Cardiovascular

The correct answer is A, B, and C. Here are the explanations for each choice:

Choice A: Monitor vital signs continuously. This is a correct and appropriate nursing intervention for the cardiovascular system. The client may have hypotension, tachycardia, or arrhythmias due to anaphylaxis or the effects of medications. Continuous monitoring can help detect any changes and guide interventions accordingly .

Choice B: Provide warmth. This is also a correct and appropriate nursing intervention for the cardiovascular system. The client may lose heat due to vasodilation, sweating, or exposure during the procedure. Providing warmth can help prevent hypothermia and shivering, which can increase oxygen demand and worsen cardiac function. Providing warmth can also improve comfort and reduce anxiety .

Choice C: Defibrillator at bedside. This is another correct and appropriate nursing intervention for the cardiovascular system. The client is at risk of cardiac arrest due to anaphylaxis, bradycardia, or pacemaker malfunction. Having a defibrillator at bedside can facilitate prompt resuscitation if needed.

Choice D: ECHO. This is an incorrect and inappropriate nursing intervention for the cardiovascular system. ECHO is a diagnostic test that uses ultrasound waves to create images of the heart and its structures. It can help evaluate the client’s cardiac function, valve function, and presence of any complications such as pericardial effusion or tamponade. However, this is not a priority intervention for the client who is experiencing an anaphylactic reaction and needs immediate treatment to stabilize her condition. ECHO can be done later after the client recovers from the acute episode.

Body System: Immunological

The correct answer is **A and D**.

- Choice A: Administer antihistamine. This is a correct and appropriate nursing intervention for the immunological system. The client is having an anaphylactic reaction to vancomycin, which is a type of hypersensitivity reaction mediated by IgE antibodies. Antihistamines, such as diphenhydramine, can block the effects of histamine, which is a major mediator of allergic inflammation and symptoms. Antihistamines can help reduce itching, hives, flushing, and bronchoconstriction¹².

- Choice B: IV fluids. This is an incorrect and inappropriate nursing intervention for the immunological system. IV fluids are not directly related to the immune response or the allergic reaction. IV fluids are mainly used to maintain hydration, electrolyte balance, and blood pressure. However, IV fluids may be indicated for the client as part of the cardiovascular or renal system interventions³.

- Choice C: Assess rash. This is an incorrect and inappropriate nursing intervention for the immunological system. Assessing rash is not a specific intervention for the immune response or the allergic reaction. Assessing rash is part of the general assessment of the client's skin condition, which may reflect other factors such as infection, inflammation, or drug toxicity. However, assessing rash may be helpful to monitor the severity and progression of the allergic reaction and the effectiveness of the treatment⁴.

- Choice D: Administer steroid. This is a correct and appropriate nursing intervention for the immunological system. The client is having an anaphylactic reaction to vancomycin, which is a type of hypersensitivity reaction mediated by IgE antibodies. Steroids, such as methylprednisolone, can suppress the immune system and reduce the production of inflammatory mediators, such as cytokines and prostaglandins. Steroids can help decrease swelling, inflammation, and tissue damage¹².

A. Print an electrocardiogram strip B. Provide rescue breaths with a manual ventilation bag C. Give naloxone 2 mg intravenously D. Apply oxygen via nasal cannula E. Perform chest compressions F. Call for rapid response

Correct Answer is ["B","C","F"]

Explanation

Choice A: Printing an electrocardiogram strip is not a priority in this situation. The client is not responsive and has a low respiratory rate, which indicates a possible overdose of morphine. The nurse should focus on reversing the effects of the opioid and maintaining the client's airway and circulation.

Choice B: Providing rescue breaths with a manual ventilation bag is a correct and urgent action. It can supply oxygen to the client until naloxone takes effect and restore normal breathing.

Choice C: Giving naloxone 2 mg intravenously is a correct and urgent action. Naloxone is an opioid antagonist that can block the effects of morphine and reverse respiratory depression.

Choice D: This can help increase the patient’s oxygen levels, which may be low due to the decreased respiratory rate.

Choice E: Performing chest compressions is not a correct or urgent action. It is only indicated if the client has no pulse or signs of life. It can also cause harm if the client has a heartbeat.

Choice F: Calling for rapid response is a correct and urgent action. Rapid response is a team of health care professionals that can assist in emergency situations and provide advanced care.

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

Patient Data Exhibits What should the nurse do immediately? Select all that apply.

Correct Answer is ["B","C","F"]

Explanation

The nurse is teaching a client with type 1 diabetes mellitus (DM) about the onset, peak, and duration of a new prescription for glargine insulin. If the insulin is administered at 0800, when is the client most likely to experience hypoglycemia?

A client with bulimia and depression who is taking phenelzine 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. Which dietary choices should the nurse instruct the client to avoid?

A client who is taking an oral dose of a tetracycline reports gastrointestinal (GI) upset. Which snack should the nurse instruct the client to take with the tetracycline?

Patient Data Exhibits For each statement, click to indicate whether the statements by the student nurse indicate understanding or no understanding of naloxone.

A client receives a prescription for 500 mL of dextrose in 5% water intravenously (IV) to be infused over 3 hours. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

A client with multiple sclerosis starts a new prescription, baclofen, to control muscle spasticity. Three days later, the client calls the clinic nurse and reports feeling fatigued and dizzy. Which instruction should the nurse provide?