The nurse is administering subcutaneous enoxaparin to a client following knee replacement surgery to prevent a deep vein thrombosis. Which laboratory result requires immediate action by the nurse?

Reference Range:

Hematocrit [42% to 52% (0.42 to 0.52 volume fraction)]

Platelets [150,000 to 400,000/mm (150 to 400 x 10L)

Creatinine (0.5 to 1.1 mg/dL (44 to 97 μmol/L)]

Blood Urea Nitrogen (BUN) [10 to 20 mg/dl (3.6 to 7.1 mmol/L)]

Serum creatinine 1.0 mg/dL (88.4 μmol/L)

Platelet count of 100,000/mm3 (100 x 10°/L).

Hematocrit 459% (0.45 volume fraction).

Blood urea nitrogen (BUN) 20 mg/dL (7.1 mmol/L)

Answer and Explanation

The Correct Answer is B

A) A serum creatinine level of 1.0 mg/dL falls within the reference range (0.5 to 1.1 mg/dL) and does not indicate immediate action by the nurse. Creatinine levels within the reference range suggest normal kidney function.

B) A platelet count of 100,000/mm3 (100 x 10^9/L) is below the lower limit of the reference range (150,000 to 400,000/mm3). Thrombocytopenia, or low platelet count, increases the risk of bleeding complications, especially when administering anticoagulants like enoxaparin. Therefore, a platelet count of 100,000/mm3 requires immediate action by the nurse to assess for bleeding and notify the healthcare provider.

C) A hematocrit of 45% (0.45 volume fraction) falls within the reference range (42% to 52%) and does not indicate immediate action by the nurse.

D) A blood urea nitrogen (BUN) level of 20 mg/dL (7.1 mmol/L) falls within the reference range (10 to 20 mg/dl) and does not indicate immediate action by the nurse.

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

A) Taking ferrous sulfate elixir with a glass of milk is not recommended because milk can interfere with the absorption of iron. Iron absorption is enhanced in an acidic environment, and milk's ca’cium content can inhibit this process.

B) Using a straw to ingest the ferrous sulfate elixir is advisable because it can help minimize contact between the medication and the teeth, reducing the risk of staining. Iron supplements can cause discoloration of the teeth, and using a straw directs the liquid towards the back of the mouth, bypassing the teeth.

C) Swallowing ferrous sulfate elixir undiluted is the usual method of administration; however, doing so may increase the risk of staining the teeth due to direct contact with the oral mucosa and teeth. It is important to follow the healthcare provider's in’tructions regarding dosage and administration.

D) Mixing ferrous sulfate elixir with an antacid is generally not recommended unless specifically directed by the healthcare provider. Antacids containing calcium or magnesium can bind to iron, forming complexes that are poorly absorbed in the gastrointestinal tract, thereby reducing the effectiveness of iron supplementation.

A. Hold the dose of IV pantoprazole until the client has finished eating breakfast. B. Provide a PRN dose of antacid along with the scheduled medications. C. Instruct the client to take the dose of sucralfate PO while eating breakfast. D. Administer both of the medications before breakfast as scheduled.

Correct Answer is D

Explanation

A) Holding the dose of IV pantoprazole until the client has finished eating breakfast may delay the onset of action of the medication, as pantoprazole is typically administered before meals to maximize its effectiveness in reducing gastric acid secretion. Additionally, delaying the dose may not provide immediate relief for the client's he’rtburn symptoms.

B) Providing a PRN dose of antacid along with the scheduled medications may temporarily relieve the client's he’rtburn symptoms, but it does not address the underlying cause of peptic ulcer disease or prevent further gastric acid secretion, which is the primary goal of pantoprazole and sucralfate administration.

C) Instructing the client to take the dose of sucralfate PO while eating breakfast may interfere with the optimal absorption of the medication. Sucralfate forms a protective barrier over ulcers in the stomach and should be administered on an empty stomach to allow it to adhere to the gastric mucosa effectively.

D) Administering both of the medications before breakfast as scheduled is the most appropriate action. Pantoprazole is a proton pump inhibitor that reduces gastric acid production, and sucralfate forms a protective barrier over ulcers in the stomach. Administering these medications before breakfast allows them to work synergistically to reduce gastric acid secretion and protect the gastric mucosa, helping to alleviate the client's he’rtburn symptoms and promote ulcer healing.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Ferrous sulfate elixir is prescribed for a client with iron deficiency anemia. Which instruction should the nurse provide this client about taking the liquid medication?

Correct Answer is B

Explanation

A client with peptic ulcer disease (PUD) is scheduled to receive doses of pantoprazole IV and sucralfate PO before breakfast at 0730. The client reports experiencing heartburn when the nurse brings the scheduled medications. Which action should the nurse take?

Correct Answer is D

Explanation

A client with a history of smoking cigarettes for many years arrives to the clinic and expresses a desire to stop smoking. The client receives a prescription for bupropion to reduce nicotine cravings. Which information should the nurse include in the discharge teaching?

A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client’s history requires follow up by the nurse?

Before administering a laxative to a bedfast client, it is most important for the nurse to perform which assessment?

A client with multiple sclerosis starts a new prescription, baclofen, to control muscle spasticity. Three days later, the client calls the clinic nurse and reports feeling fatigued and dizzy. Which instruction should the nurse provide?

A female client who is starting a new prescription for doxycycline hyclate tells the nurse that she takes birth control pills. Which action should the nurse take?

Six days after starting a prescription of an oral amoxicillin solution, a client calls the clinic to report the onset of a low grade fever. Which action should the nurse Implement?

The loop diuretic furosemide is prescribed for a client with a history of heart failure (HF). Which foods should the nurse encourage this client to eat?