Which serum laboratory test is most important for the nurse to monitor when administering enoxaparin to a client?

Protein and albumin.

Complete blood count (CBC).

BUN and creatinine.

Electrolytes.

Answer and Explanation

The Correct Answer is B

Choice A reason: Protein and albumin reflect nutritional or liver status but are unaffected by enoxaparin, a low-molecular-weight heparin inhibiting factor Xa. These do not monitor anticoagulation effects or complications like bleeding. CBC is critical, as enoxaparin increases bleeding risk, requiring platelet and hemoglobin monitoring to detect serious hematological issues.

Choice B reason: Enoxaparin, an anticoagulant, heightens bleeding risk and can cause thrombocytopenia. Monitoring CBC, especially platelets and hemoglobin, detects heparin-induced thrombocytopenia (HIT) or hemorrhage. This ensures early identification of complications, allowing timely intervention to prevent severe bleeding or thrombosis, making CBC the most critical test for safe administration.

Choice C reason: BUN and creatinine assess renal function, relevant for renally cleared drugs, but enoxaparin is primarily liver-metabolized. Renal monitoring is secondary unless severe impairment exists. CBC is more urgent, as enoxaparin’s anticoagulant effect increases bleeding risk, necessitating hematological surveillance to prevent life-threatening complications.

Choice D reason: Electrolytes like potassium or sodium are not directly affected by enoxaparin’s action on the coagulation cascade. Imbalances may occur in critical illness but are not primary concerns. CBC monitoring for bleeding or thrombocytopenia is critical, as enoxaparin’s anti-Xa activity poses hematological risks requiring immediate attention.

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Correct Answer is C

Explanation

Choice A reason: Measuring glucose monitors corticosteroid-induced hyperglycemia, but a rigid abdomen with rebound tenderness suggests peritonitis, possibly from IBD-related perforation. Vital signs detect systemic effects like sepsis (e.g., tachycardia), more urgent than glucose, as perforation is a life-threatening emergency requiring immediate intervention to prevent shock.

Choice B reason: Monitoring bloody diarrhea is relevant in IBD, but a rigid abdomen with rebound tenderness indicates peritonitis, likely from perforation. Vital signs assess systemic stability (e.g., fever, hypotension), critical for detecting life-threatening complications like sepsis, making this more urgent than tracking expected IBD symptoms.

Choice C reason: A rigid abdomen with rebound tenderness suggests peritonitis from bowel perforation in IBD, causing peritoneal irritation. Vital signs (e.g., heart rate, BP, temperature) detect shock or infection, guiding urgent interventions like surgery or antibiotics. This assessment prioritizes rapid response to a potentially fatal surgical emergency.

Choice D reason: Encouraging ambulation is contraindicated with a rigid abdomen and rebound tenderness, indicating peritonitis. Movement may worsen peritoneal irritation or infection spread. Vital signs assess systemic compromise, critical for managing perforation, ensuring timely intervention to prevent sepsis or shock, making ambulation inappropriate.

A. Observe for change in breathing pattern. B. Palpate the volume of pedal pulses. C. Assess for inflammation of the calves. D. Inspect for distention of peripheral veins.

Correct Answer is A

Explanation

Choice A reason: Increased JVD and pedal edema indicate fluid overload in heart failure, where reduced cardiac output causes venous congestion. Assessing breathing for dyspnea or crackles detects pulmonary edema, as fluid backs into alveoli, impairing gas exchange. This urgent finding guides interventions like diuretics, critical before reporting.

Choice B reason: Palpating pedal pulses assesses arterial flow, not fluid overload causing JVD and edema, which are venous issues in heart failure. Pulses may be normal despite congestion. Breathing changes indicate pulmonary edema, a life-threatening complication, making this assessment more critical for detecting acute decompensation.

Choice C reason: Assessing calf inflammation may detect thrombosis, a heart failure risk, but JVD and edema suggest fluid overload, not clotting. Breathing changes are more urgent, indicating pulmonary edema from alveolar fluid, requiring immediate intervention to prevent respiratory failure, unlike inflammation, which is less immediate.

Choice D reason: Inspecting peripheral vein distention confirms venous congestion but is less critical than breathing assessment. In heart failure, fluid overload risks pulmonary edema, where alveolar fluid causes dyspnea. Monitoring breathing detects this severe complication, prioritizing intervention to ensure oxygenation over additional venous assessment.

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Which serum laboratory test is most important for the nurse to monitor when administering enoxaparin to a client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is hospitalized with an inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid. The client develops a rigid abdomen with rebound tenderness. Which action should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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