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)]

A) Take the benzodiazepine at the same time of taking the morphine: This statement is incorrect. Benzodiazepines and morphine are both central nervous system depressants and can potentiate each other’s effects, leading to increased sedation and respiratory depression. Taking them together without proper supervision or dosage adjustment can be dangerous. Therefore, this statement indicates a misunderstanding of the medication regimen.

B) Do not drink grapefruit juice after taking morphine: While grapefruit juice can interact with certain medications by affecting their metabolism, there is no specific interaction between grapefruit juice and morphine that requires avoidance. Therefore, this statement is not directly related to the use of morphine for bone pain.

C) Watch for signs of agitation and record any insomnia: While it is important to monitor for side effects of morphine, such as agitation and insomnia, this statement does not directly relate to the management of constipation, which is a common side effect of opioid analgesics like morphine.

D) Observe bowel movement pattern and take a stool softener: This is the correct answer. Morphine is known to cause constipation as a side effect due to its action on opioid receptors in the gastrointestinal tract. Therefore, monitoring bowel movements and taking a stool softener can help prevent or alleviate constipation associated with morphine use. This statement indicates an understanding of the potential side effects of the medication and the importance of managing them appropriately.

A) Deep-fried shrimp: While deep-fried foods are generally high in fat and calories, there is no specific contraindication for clients taking phenelzine to avoid deep-fried shrimp. However, clients with hypertension may benefit from reducing their intake of high-fat foods.

B) Pan-seared catfish: Pan-seared catfish is a relatively lean protein source and does not contain ingredients known to interact with phenelzine. However, clients with hypertension may benefit from limiting their intake of high-sodium foods, such as pan-seared catfish if it is prepared with added salt.

C) Pepperoni pizza: Pepperoni pizza is a high-sodium food due to its processed meat toppings and cheese, and it may contain ingredients that interact with phenelzine. Phenelzine is a monoamine oxidase inhibitor (MAOI), and consuming foods high in tyramine, such as aged or fermented foods like pepperoni, can lead to hypertensive crisis. Therefore, the nurse should instruct the client to avoid pepperoni pizza to prevent potential interactions and exacerbation of hypertension.

D) Beef tips with gravy: While beef tips with gravy may be high in sodium depending on how it is prepared, there is no specific contraindication for clients taking phenelzine to avoid this food. However, clients with hypertension may benefit from choosing lean cuts of beef and limiting their intake of high-sodium gravies.