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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Positioning right lateral with head elevation may shift fluid but does not restore drain suction. Compressing the bulb creates negative pressure, promoting drainage. Positioning is less effective, per surgical drain management and postoperative care standards in nursing practice.

Choice B reason: Compressing the bulb with the tab open, then reinserting it, restores negative pressure, enhancing drainage in the surgical drain. This ensures fluid removal, preventing hematoma or infection, per evidence-based surgical drain management and postoperative care protocols in nursing practice.

Choice C reason: Irrigating the drain with saline risks infection and is not standard for low drainage. Compressing the bulb restores suction, promoting drainage safely. Irrigation is inappropriate, per surgical drain management and infection control standards in postoperative nursing care.

Choice D reason: Reinforcing dressings and assessing drainage addresses symptoms, not the cause of low drainage. Compressing the bulb restores suction, increasing drainage effectively. Dressings are secondary, per surgical drain management and postoperative wound care protocols in nursing practice.

A. Go to the emergency room as soon as possible for glucose administration. B. Drink regular cola fluids frequently throughout the day until the nausea subsides. C. Continue to monitor blood glucose levels and drink fluids as tolerated. D. Do not inject any additional insulin until solid food can be tolerated.

Correct Answer is C

Explanation

Choice A reason: Going to the ER for glucose is unnecessary unless hypoglycemia or ketoacidosis is confirmed. Type 1 diabetes with nausea risks hyperglycemia from stress hormones like cortisol. Monitoring glucose and fluids manages the condition at home, preventing escalation unless severe symptoms arise, making this instruction premature.

Choice B reason: Drinking regular cola introduces high sugar, risking hyperglycemia in type 1 diabetes, where insulin deficiency impairs glucose uptake. Stress from illness elevates glucose via glucagon. Monitoring with non-sugar fluids prevents dehydration and ketoacidosis, making this advice dangerous and ineffective for diabetes management.

Choice C reason: Monitoring blood glucose and drinking fluids is critical in type 1 diabetes during illness. Nausea reduces intake, and stress hormones raise glucose, risking ketoacidosis. Frequent checks guide insulin adjustments, and fluids prevent dehydration, maintaining metabolic stability, addressing the physiological needs of insulin deficiency and infection.

Choice D reason: Avoiding insulin risks diabetic ketoacidosis, as type 1 diabetes requires basal insulin despite nausea. Illness increases glucose via stress hormones, even without food. Monitoring allows tailored dosing, preventing hyperglycemia, making this instruction harmful, as it ignores ongoing insulin needs for metabolic control.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 who had a radical neck dissection returns to the surgical unit with two surgical drains in the right side of the incision. One drain bulb is open and has minimal drainage. Which action should the nurse take to increase drainage into the drain?

Correct Answer is B

Explanation

A client with type 1 diabetes mellitus calls the home care nurse and reports taking a morning dose of 70/30 insulin before realizing they have a stomach virus and are now unable to eat breakfast due to nausea. Which initial instruction should the nurse provide?

Correct Answer is C

Explanation

A client with a history of atrial fibrillation is prescribed warfarin. The nurse notes the client’s INR is 4.8. Which action should the nurse take? Reference Range: INR [2.0 to 3.0 for atrial fibrillation].

Which client’s laboratory value requires immediate intervention by a nurse? Reference Range: Hemoglobin (Hgb) [14 to 18 g/dL (8.7 to 11.2 mmol/L)]; Fasting Blood Glucose [70 to 110 mg/dL (3.9 to 6.1 mmol/L)]; Neutrophils (ANC) [55 to 70%: 2,500 to 8,000/mm3 (2.5 to 5.8 x109/L)]

The nurse measures the client’s blood pressure (BP) and notes that it is significantly higher than the previous reading. Which should the nurse do next? (Select all that apply)

After placing a client who is having a seizure in the side-lying position, which intervention should the nurse implement?

After a client voids, 150 mL of residual urine is measured. Which nursing problem should be included in this client’s plan of care?

Which nursing intervention is most effective in determining the severity of a client’s pain?

The nurse is developing a teaching plan for a client with peripheral arterial disease (PAD) who has a history of myocardial infarction (MI) and smokes two packs of cigarettes daily. Which instruction has the highest priority?

When the nurse discontinues a 24-hour postoperative client’s patient-controlled analgesia (PCA) pump, the client asks to go to the hospital’s smoking area to smoke a cigarette. Which response should the nurse provide?