A client with deep vein thrombosis (DVT) is prescribed enoxaparin, a low molecular weight heparin (LMWH). What is the nurse's priority action before administering the medication?
Measuring the client's blood pressure.
Assessing the client's platelet count.
Ensuring the client has an indwelling urinary catheter.
Obtaining the client's weight.
None
None
The Correct Answer is D
A. Measuring the client's blood pressure is an important assessment but is not the immediate priority when preparing to administer enoxaparin.
B. Assessing the client's platelet count is critical before administering enoxaparin, especially because low molecular weight heparins can lead to heparin-induced thrombocytopenia (HIT). Monitoring platelet levels helps to ensure the client's safety and prevent complications.
C. Ensuring the client has an indwelling urinary catheter is not necessary for the administration of enoxaparin and does not relate to its safety or efficacy.
D. Obtaining the client's weight is relevant for dosing but is secondary to assessing the platelet count, particularly in light of the risk of HIT.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) This choice is correct. Gender is a non-modifiable risk factor for DVT, with women generally having a higher risk than men. Hormonal changes, such as those associated with pregnancy, oral contraceptives, and hormone replacement therapy, can contribute to the increased risk in women.
B) This choice is incorrect because obesity is a modifiable risk factor for DVT, not a non-modifiable one. Clients can work to achieve and maintain a healthy weight to reduce their risk.
C) This choice is incorrect because smoking history is a modifiable risk factor for DVT. Clients can quit smoking to decrease their risk of blood clot formation.
D) This choice is incorrect because a sedentary lifestyle is a modifiable risk factor for DVT. Clients can engage in regular physical activity to reduce their risk.
Correct Answer is B
Explanation
A) This choice is incorrect because while monitoring blood pressure is essential, it is not the priority action for clients on anticoagulant therapy. The primary concern is assessing the client's response to the medication and their risk of bleeding.
B) This choice is correct. Monitoring the client's prothrombin time (PT) and international normalized ratio (INR) is crucial in assessing the effectiveness of anticoagulant therapy. The PT and INR measure how long it takes the blood to clot and help determine the appropriate dosage of anticoagulants to achieve the desired therapeutic effect.
C) This choice is incorrect because checking the client's blood glucose levels is not directly related to monitoring the response to anticoagulant therapy. Blood glucose monitoring is essential for clients with diabetes but not a priority in this context.
D) This choice is incorrect because evaluating the client's respiratory rate and pattern is not the priority action for monitoring the response to anticoagulant therapy. Respiratory assessment is vital in detecting potential complications like a pulmonary embolism but does not directly assess the client's anticoagulation status.
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