While preparing to administer a client's morning medications, the nurse notes the client is to receive heparin 5,000 units subcutaneously and has a new order for enoxaparin. What action should the nurse take?
Check the client's activated partial thromboplastin time (aPTT).
Hold both medications and clarify the order with the prescriber.
Administer the injections in separate sites.
Administer the enoxaparin and hold the heparin.
The Correct Answer is B
A. Check the client's activated partial thromboplastin time (aPTT): While aPTT is used to monitor unfractionated heparin therapy, it does not address the potential issue of duplicate anticoagulation therapy. Relying solely on lab values could put the client at risk for serious bleeding.
B. Hold both medications and clarify the order with the prescriber: Administering both heparin and enoxaparin without clarification can result in excessive anticoagulation and significant bleeding risk. Holding the medications and contacting the prescriber ensures safe medication administration and prevents potential adverse effects.
C. Administer the injections in separate sites: Even if given in separate sites, administering both heparin and enoxaparin simultaneously could lead to additive anticoagulant effects and increase the risk of hemorrhage. Site separation does not mitigate systemic risks.
D. Administer the enoxaparin and hold the heparin: Giving enoxaparin without clarifying the order for heparin could result in duplicate anticoagulation, increasing the potential for bleeding complications. Safe practice requires prescriber clarification before administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A client with benign prostatic hyperplasia: Terazosin is an alpha-1 adrenergic blocker that relaxes smooth muscle in the prostate and bladder neck, improving urine flow and reducing symptoms of BPH such as urinary hesitancy and incomplete bladder emptying.
B. A client with a history of syncope: Terazosin can cause orthostatic hypotension, especially with the first dose, increasing the risk of dizziness and fainting. Administering it to a client prone to syncope could exacerbate this risk.
C. A client with fluid volume deficit: Hypovolemia can intensify the blood pressure–lowering effects of terazosin, increasing the likelihood of symptomatic hypotension and falls. Careful assessment and correction of fluid status are necessary before administration.
D. A client with hypotension: Terazosin lowers blood pressure by vasodilation. Administering it to a client who already has hypotension could cause severe hypotensive episodes, dizziness, or shock.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
Explanation
Blood pressures be monitored regularly at home: Monitoring blood pressure at home helps the client track the effectiveness of antihypertensive therapy and detect trends that may require dose adjustments. It promotes early recognition of uncontrolled hypertension and allows timely communication with the healthcare provider.
• A low-sodium diet is recommended: Excess sodium intake contributes to fluid retention and increased blood pressure. Educating the client about reducing sodium supports medication efficacy and helps manage hypertension. Dietary modifications complement pharmacologic therapy to improve cardiovascular outcomes.
• Do not stop taking the medication abruptly: Abrupt discontinuation of antihypertensive medications can lead to rebound hypertension, which may cause stroke, myocardial infarction, or other cardiovascular complications. Clients should be educated to taper medications only under the guidance of a healthcare provider.
• Engage in regular exercise: Regular physical activity helps lower blood pressure by improving cardiovascular efficiency, reducing weight, and promoting vascular health. Exercise is an essential nonpharmacologic strategy that complements antihypertensive therapy and supports long-term blood pressure control.
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