A nurse is reinforcing teaching with a client who is taking enoxaparin. Which of the following statements by the client indicates an understanding of the teaching?
"will use ibuprofen when I have a headache.”
“will use an electric razor for shaving”
“will avoid the use of stool softeners."
"I will massage the site after each injection.”
The Correct Answer is B
Choice A Reason:
"Will use ibuprofen when I have a headache." This statement is inappropriate. Enoxaparin is an anticoagulant, and using nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can increase the risk of bleeding. So, using ibuprofen isn't recommended without consulting a healthcare professional while on enoxaparin.
Choice B Reason:
“Will use an electric razor for shaving.” This statement is correct. Enoxaparin is an anticoagulant, and using a sharp razor increases the risk of bleeding. Using an electric razor reduces the chance of nicks or cuts that could lead to bleeding complications while on this medication.
Choice C Reason:
“Will avoid the use of stool softeners." This statement is inappropriate. Enoxaparin doesn't directly interact with stool softeners. However, it's crucial to consult a healthcare provider before taking any new medications, including stool softeners, while on enoxaparin, as there might be potential interactions or effects on clotting.
Choice D Reason:
"I will massage the site after each injection." This statement is inappropriate. Massaging the site after an enoxaparin injection could potentially cause bruising or irritation. The usual recommendation is to apply gentle pressure at the injection site for a short time after the injection but not to massage it vigorously.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
The client has a delayed response to verbal commands. This finding can indicate increased intracranial pressure. Changes in responsiveness, such as delayed responses to verbal commands or other stimuli, can be indicative of neurological impairment due to elevated pressure within the skull.
Choice B Reason:
The client has ecchymosis around the eyes. Ecchymosis around the eyes (raccoon eyes) can occur with certain head injuries, but it's not a direct sign of increased intracranial pressure. It's more commonly associated with basilar skull fractures rather than specifically reflecting increased pressure within the skull.
Choice C Reason:
The client is unable to remember details of the motor-vehicle crash. Memory impairment or amnesia regarding the event can occur due to head trauma, but it might not directly correlate with an increase in intracranial pressure. It's more related to the effects of the injury on memory function.
Choice D Reason:
The client reports ringing in the ears. Tinnitus or ringing in the ears might occur in some cases of head trauma but is not a direct indicator of increased intracranial pressure. It might result from the impact of the injury or other associated factors.
Correct Answer is A
Explanation
Choice A Reason:
Replace the unit when the drainage chamber is full is correct. Regularly emptying the drainage chamber when it becomes full is essential to ensure the drainage system functions properly and continues to effectively remove fluids or air from the chest cavity.
Choice B Reason:
Clamp the tube for 30 min every 8 hr. is incorrect.
Clamping a chest tube without a specific medical order or indication can lead to complications such as a buildup of pressure within the chest cavity or potential damage to the lungs. It's generally not a routine action to clamp the tube without proper instruction.
Choice C Reason:
Pin the tubing to the client's bed sheets is incorrect. Pinning the tubing to the bed sheets can cause tension on the chest tube, leading to accidental dislodgment or obstruction. The tubing should be secured but not pinned to prevent inadvertent movement.
Choice D Reason:
Monitor for at least 150 mL of drainage every hour is incorrect. There isn't a standard or prescribed amount of drainage that should occur hourly. The nurse should monitor the drainage rate and characteristics but shouldn't expect a specific volume within a set timeframe. Monitoring for excessive or decreased drainage and changes in characteristics is crucial, but an hourly volume expectation isn't appropriate.
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