Which serum laboratory test is most important for the nurse to monitor when administering enoxaparin to a client?

Protein and albumin.

Complete blood count (CBC).

BUN and creatinine.

Electrolytes.

Answer and Explanation

The Correct Answer is B

Choice A reason: Protein and albumin reflect nutritional or liver status but are unaffected by enoxaparin, a low-molecular-weight heparin inhibiting factor Xa. These do not monitor anticoagulation effects or complications like bleeding. CBC is critical, as enoxaparin increases bleeding risk, requiring platelet and hemoglobin monitoring to detect serious hematological issues.

Choice B reason: Enoxaparin, an anticoagulant, heightens bleeding risk and can cause thrombocytopenia. Monitoring CBC, especially platelets and hemoglobin, detects heparin-induced thrombocytopenia (HIT) or hemorrhage. This ensures early identification of complications, allowing timely intervention to prevent severe bleeding or thrombosis, making CBC the most critical test for safe administration.

Choice C reason: BUN and creatinine assess renal function, relevant for renally cleared drugs, but enoxaparin is primarily liver-metabolized. Renal monitoring is secondary unless severe impairment exists. CBC is more urgent, as enoxaparin’s anticoagulant effect increases bleeding risk, necessitating hematological surveillance to prevent life-threatening complications.

Choice D reason: Electrolytes like potassium or sodium are not directly affected by enoxaparin’s action on the coagulation cascade. Imbalances may occur in critical illness but are not primary concerns. CBC monitoring for bleeding or thrombocytopenia is critical, as enoxaparin’s anti-Xa activity poses hematological risks requiring immediate attention.

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Correct Answer is C

Explanation

Choice A reason: Dry skin and inelastic turgor reflect dehydration in DI from antidiuretic hormone deficiency, causing water loss. This is less urgent than hypernatremia (185 mEq/L), which dehydrates brain cells, risking seizures or coma, requiring immediate fluid correction to prevent neurological damage in this critical condition.

Choice B reason: Tachycardia (110 beats/minute) compensates for hypovolemia in DI, where water loss reduces preload, triggering sympathetic activation. This is less critical than hypernatremia (185 mEq/L), which causes cerebral dehydration, necessitating urgent hypotonic fluids to prevent neurological complications, making heart rate secondary.

Choice C reason: Serum sodium of 185 mEq/L indicates severe hypernatremia in DI, where water loss concentrates sodium, dehydrating neurons and risking seizures or coma. Immediate IV hypotonic fluids (e.g., 5% dextrose) correct osmolarity, preventing life-threatening cerebral complications, addressing the urgent pathophysiological crisis in DI.

Choice D reason: Polyuria and thirst are hallmark DI symptoms from water loss but expected and less urgent than hypernatremia (185 mEq/L), which threatens neurological function via osmotic brain injury. Correcting sodium is critical to prevent seizures, making these symptoms secondary to urgent electrolyte management.

A. Evaluate amount of urinary output hourly. B. Clamp the catheter for 5 minutes hourly. C. Secure the ureteral catheter to the client’s leg. D. Report urine leakage around ureteral catheter.

Correct Answer is D

Explanation

Choice A reason: Evaluating urinary output hourly monitors renal function post-ureterolithotomy, as obstruction or complications may reduce output. However, urine leakage around the catheter suggests dislodgement or ureteral injury, risking peritonitis or infection. Reporting leakage is more urgent, as it indicates a critical catheter malfunction requiring immediate medical attention.

Choice B reason: Clamping the ureteral catheter risks obstructing urine flow, increasing pressure and causing ureteral damage or reflux, potentially leading to hydronephrosis or infection. Leakage around the catheter is a more pressing issue, indicating possible perforation or displacement, necessitating urgent reporting to prevent severe complications.

Choice C reason: Securing the catheter prevents dislodgement but is routine. Urine leakage suggests a critical issue like catheter malfunction or ureteral injury, which could cause peritonitis or fistula. Reporting leakage takes precedence, as it addresses a potentially life-threatening complication, ensuring timely intervention over standard catheter care.

Choice D reason: Reporting urine leakage is critical, as it may indicate catheter displacement or ureteral perforation, risking peritonitis or infection. Leakage suggests the catheter fails to drain urine properly, a serious post-surgical issue requiring immediate assessment, potentially via imaging or surgical correction, to prevent renal or systemic complications.

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Which serum laboratory test is most important for the nurse to monitor when administering enoxaparin to a client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which data warrants the most immediate intervention by the nurse for a client with diabetes insipidus (DI)? Reference Range: Sodium [136 to 145 mEq/L (136 to 145 mmol/L)].

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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