The nurse is caring for a client with pulmonary embolism who is receiving enoxaparin. Which of the following actions should the nurse include in the plan of care?

Administering medication slowly via an intramuscular injection

Having vitamin K available in case of excessive bleeding

Checking the aPTT results before administering the medication

Monitoring platelet counts during the therapy

Answer and Explanation

The Correct Answer is D

A. Enoxaparin is a low molecular weight heparin (LMWH) and should never be given intramuscularly because IM injections increase the risk of hematoma formation. It is administered subcutaneously.

B. Vitamin K is the antidote for warfarin, not enoxaparin. For LMWH, protamine sulfate is used to reverse anticoagulation if needed.

C. Routine monitoring of aPTT is not required with LMWH like enoxaparin because it has a predictable anticoagulant effect. Monitoring is typically reserved for special populations, such as renal impairment or obesity.

D. Enoxaparin carries a risk of heparin-induced thrombocytopenia (HIT), a potentially life-threatening complication. Platelet counts should be monitored regularly, especially during the first 2 weeks of therapy, to detect early thrombocytopenia and prevent complications.

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Correct Answer is D

Explanation

A. That there is a high potential for acute respiratory distress syndromeis incorrect because although ARDS can occur after severe trauma, it is not the immediate guiding principle during initial emergency assessment. The primary focus is stabilization and prevention of further injury.

B. That the risk of survival is likely very lowis incorrect because assumptions about survival do not guide safe clinical care. Trauma management is focused on systematic assessment and rapid intervention to improve survival outcomes.

C. That there is likely for multiple bone fracturesis incorrect because while fractures are common in motor vehicle collisions, they are not the highest priority concern during initial assessment. Airway, breathing, circulation, and spinal protection take precedence.

D. That a spinal cord injury exists until proven otherwiseis correct because in any client involved in significant trauma, especially a motor vehicle collision, spinal injury must be assumed. Maintaining spinal immobilization and preventing neck movement are critical to avoid further neurological damage. This principle aligns with trauma protocols emphasizing spinal precautions during primary survey assessment.

A. Tighten the straps on the nasal cannula B. Increase the oxygen flow rate to 8 L/min C. Check the tubing for kinks, leaks, or obstructions D. Check to determine whether the oxygen delivery system is adequately humidified

Correct Answer is C

Explanation

A. While properly securing the cannula is important for comfort and consistent oxygen delivery, it is unlikely to be the primary cause of a significant drop in SpO2unless the cannula is completely dislodged.

B. Immediately increasing the flow rate without assessing the equipment or patient may be premature. The drop in SpO2 could be caused by mechanical issues or patient factorsthat need to be addressed first. Additionally, flow rates above 6 L/min are generally not recommended for standard nasal cannulabecause they can cause mucosal dryness and discomfort.

C. The first action is to ensure the oxygen delivery system is functioning properly, as tubing obstruction, disconnection, or leaks are common, reversible causes of hypoxemia. Correcting these issues can immediately improve oxygenationbefore escalating care or altering prescriptions.

D. Humidification improves comfort and prevents mucosal dryness, but it does not immediately affect oxygen saturation. Ensuring proper tubing function takes priority.

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The nurse is caring for a client with pulmonary embolism who is receiving enoxaparin. Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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