While assessing a client's health history, the nurse notes that the client has been receiving enoxaparin. Which health outcome would indicate this medication is effective?

Reference Range:

Glycosylated hemoglobin (A1C) [4% to 5.9% ]

Hemoglobin (Hgb) [12 to 16 g/dL (120 to 160 g/L)]

The client's glycosylated hemoglobin A1C is below 7%.

The client does not develop deep vein thrombosis (DVT) after abdominal surgery.

The client's hemoglobin remains above 14 g/dL (140 g/L).

The pulmonary embolus has lysed and the client's respiratory status improves.

Answer and Explanation

The Correct Answer is B

Rationale:
A. The client's glycosylated hemoglobin A1C is below 7%: A1C reflects long-term blood glucose control, which is unrelated to the anticoagulant effects of enoxaparin. It does not indicate the medication’s effectiveness in preventing clot formation.

B. The client does not develop deep vein thrombosis (DVT) after abdominal surgery: Enoxaparin is a low-molecular-weight heparin used to prevent thrombus formation. The absence of DVT postoperatively demonstrates that the anticoagulant is achieving its intended prophylactic effect.

C. The client's hemoglobin remains above 14 g/dL (140 g/L): Hemoglobin levels indicate anemia status but are not a measure of anticoagulant effectiveness. While significant bleeding could lower Hgb, normal levels alone do not confirm therapeutic efficacy.

D. The pulmonary embolus has lysed and the client's respiratory status improves: Enoxaparin prevents new clot formation but does not actively lyse existing thrombi. Improvement in a pulmonary embolus would require other interventions, such as thrombolytic therapy.

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Correct Answer is ["A","D","E"]

Explanation

Rationale:
A. Send wound drainage for culture and sensitivity: Obtaining a culture identifies MRSA as the causative organism and determines antibiotic susceptibility. This guides targeted antimicrobial therapy and reduces the risk of treatment failure. Accurate identification is essential for infection control and clinical management.

B. Explain the purpose of a low bacteria diet: A low bacteria (neutropenic) diet is reserved for clients with severe immunosuppression, such as those undergoing chemotherapy. Localized MRSA wound infections do not require dietary bacterial restriction. Nutrition should focus on adequate protein and calories for wound healing.

C. Use standard precautions and wear a mask: MRSA wound infections require standard precautions plus contact precautions. A mask is not routinely required unless there is risk of splashing or respiratory involvement. Gloves and gowns are the primary protective measures.

D. Institute contact precautions for staff and visitors: MRSA is transmitted via direct and indirect contact with contaminated surfaces or drainage. Contact precautions, including gloves and gowns, reduce transmission to healthcare workers and other clients. These precautions are essential in preventing hospital-acquired spread.

E. Monitor the client's white blood cell count (WBC): The WBC count helps assess the presence and progression of infection and the client’s response to treatment. Trends in WBC levels can indicate worsening infection or resolution. Ongoing monitoring supports timely clinical decision-making.

A. Monitor ETT markings between 22 and 26 cm at teeth line. B. Check for capillary refill of 3 seconds or less. C. Auscultate for presence of bilateral breath sounds. D. Obtain a portable chest x-ray to verify ETT location. E. Assess for symmetrical chest movement.

Correct Answer is ["A","C","D","E"]

Explanation

Rationale:
A. Monitor ETT markings between 22 and 26 cm at teeth line: Proper placement is often estimated using standard depth markings on the ETT. Securing the tube at an appropriate depth ensures it is in the trachea rather than the esophagus, reducing the risk of hypoxia or lung injury.

B. Check for capillary refill of 3 seconds or less: Capillary refill assesses peripheral perfusion, not airway placement. It does not provide any information regarding correct ETT positioning or ventilation effectiveness.

C. Auscultate for presence of bilateral breath sounds: Listening to breath sounds in both lungs confirms that the tube is in the trachea and not selectively intubating one bronchus. Bilateral sounds indicate effective ventilation and proper tube placement.

D. Obtain a portable chest x-ray to verify ETT location: Chest radiography is the definitive method to confirm correct ETT placement in the trachea and its depth above the carina. This is standard practice after intubation in an emergency setting.

E. Assess for symmetrical chest movement: Observing equal chest rise and fall during ventilation indicates the ETT is correctly positioned in the trachea and that both lungs are being ventilated. Asymmetry may suggest endobronchial intubation or pneumothorax.

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While assessing a client's health history, the nurse notes that the client has been receiving enoxaparin. Which health outcome would indicate this medication is effective? Reference Range: Glycosylated hemoglobin (A1C) [4% to 5.9% ] Hemoglobin (Hgb) [12 to 16 g/dL (120 to 160 g/L)]

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A client with foul smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care (POC)? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

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While assessing a client's health history, the nurse notes that the client has been receiving enoxaparin. Which health outcome would indicate this medication is effective? Reference Range: Glycosylated hemoglobin (A1C) [4% to 5.9% ] Hemoglobin (Hgb) [12 to 16 g/dL (120 to 160 g/L)]

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While assessing a client's health history, the nurse notes that the client has been receiving enoxaparin. Which health outcome would indicate this medication is effective?

Reference Range:

Glycosylated hemoglobin (A1C) [4% to 5.9% ]

Hemoglobin (Hgb) [12 to 16 g/dL (120 to 160 g/L)]