The nurse cares for a client receiving Enoxaparin subcutaneously to prevent deep vein thrombosis (DVT). Which assessment findings should be reported to the health care provider immediately?

The client's stool is a dark green liquid.

The client's aPTT time is twice their baseline.

The client has a few abdominal bruises.

The client's blood pressure is 88/46.

Answer and Explanation

The Correct Answer is D

A. Dark green liquid stool is not a typical sign of bleeding; black, tarry stools (melena) would be concerning.
B. Enoxaparin (a low-molecular-weight heparin) does not require routine aPTT monitoring; this finding is less relevant.
C. Minor bruising can occur with anticoagulant therapy and may not require immediate reporting unless extensive.
D. Hypotension (BP 88/46) can indicate bleeding or hemorrhage, which is a serious adverse effect of enoxaparin and should be reported immediately.

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Correct Answer is C

Explanation

A. The nurse does not determine the presence or absence of mental illness; this is a medical assessment.
B. The spouse’s agreement is not required for the client’s consent; consent must come directly from the client if competent.
C. The nurse’s signature as a witness confirms that the client appears competent and voluntarily signs the consent form.
D. It is the provider’s responsibility, not the nurse’s, to explain the risks and benefits of the procedure.

A. Dependent positioning of the client's extremities when at rest B. Doppler ultrasound of peripheral circulation twice daily C. Early ambulation and leg exercises D. Cessation of oral contraceptives until 3 weeks postoperative

Correct Answer is C

Explanation

A. Dependent positioning can increase the risk of venous pooling and thrombosis.
B. Doppler ultrasound may be used if there is a suspicion of thrombosis but is not a standard preventative intervention.
C. Early ambulation and leg exercises promote circulation and reduce the risk of deep vein thrombosis, which is increased by oral contraceptive use.
D. Stopping oral contraceptives pre- or postoperatively is a physician’s decision, not a nursing intervention.

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The nurse cares for a client receiving Enoxaparin subcutaneously to prevent deep vein thrombosis (DVT). Which assessment findings should be reported to the health care provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a preoperative client. The nurse signs as a witness on the client's consent form. Which of the following does the nurse's signature on the consent form indicate?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

A nurse is caring for a client with type 1 diabetes. The client's medication administration record includes the administration of Humulin-R (regular insulin or Novolin-R three times daily. Knowing that the client's lunch tray will arrive at 11:45 AM, when should the nurse administer the insulin?

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