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 B

Explanation

Choice A reason: Blood pressure of 142/88 mm Hg indicates mild hypertension but does not directly affect pulse oximetry, which measures arterial oxygen saturation via hemoglobin light absorption. Hypertension does not typically cause hypoxemia (91% SpO₂). Edema is more likely, as it disrupts sensor accuracy, leading to false low readings.

Choice B reason: 2+ edema in fingers and hands impairs pulse oximeter accuracy, as fluid in tissues scatters light, reducing the sensor’s ability to detect arterial hemoglobin saturation. This causes falsely low SpO₂ readings (91%), common in edema from heart failure, making it the primary contributor to the inaccurate measurement.

Choice C reason: A radial pulse volume of 3+ indicates strong arterial flow, supporting accurate pulse oximetry by ensuring perfusion. This does not explain a low SpO₂ of 91%, as strong pulses enhance sensor reliability. Edema’s interference with light transmission is more likely to cause the reduced reading.

Choice D reason: Capillary refill of 2 seconds is normal, indicating adequate perfusion. This does not contribute to a low SpO₂ (91%), as pulse oximetry measures arterial flow, not capillary dynamics. Edema disrupts light transmission, causing inaccurate readings, making it the most likely cause of the observed saturation.

A. “Your PCA pump has just been discontinued, and you need to wait at least one hour before leaving the unit.” B. “As long as you go to the smoking area in a wheelchair, it will be all right for you to go smoke.” C. “You may smoke in your room if you keep the door closed and open a window.” D. “Smoking is hazardous to your health, and since you just had surgery, it would be best for you to avoid smoking.”

Correct Answer is D

Explanation

Choice A reason: Delaying smoking for one hour is arbitrary and does not address smoking’s risks post-surgery. Nicotine causes vasoconstriction, reducing wound perfusion, and carbon monoxide impairs oxygen delivery, delaying healing. Advising against smoking mitigates these risks, promoting recovery, making this response less effective than cessation advice.

Choice B reason: Allowing smoking in a wheelchair ignores postoperative risks. Nicotine’s vasoconstriction reduces tissue oxygenation, and carbon monoxide lowers hemoglobin’s capacity, impairing healing. This increases infection or thrombosis risk. Advising against smoking addresses these physiological harms, prioritizing wound recovery over facilitating smoking, which is detrimental.

Choice C reason: Smoking in the room violates hospital safety and exposes others to secondhand smoke. Nicotine and carbon monoxide reduce tissue perfusion and oxygen delivery, delaying postoperative healing. Advising against smoking prevents these complications, ensuring better recovery, making this response unsafe and inappropriate for surgical patients.

Choice D reason: Advising against smoking is critical, as nicotine causes vasoconstriction, reducing blood flow to surgical sites, and carbon monoxide impairs oxygen delivery, delaying healing. These increase infection and thrombosis risks post-surgery. This response promotes optimal recovery, addressing physiological needs for wound healing in the critical 24-hour period.

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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

The nurse attaches a pulse oximeter to a client’s finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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