Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has deep vein thrombosis and is receiving enoxaparin therapy subcutaneously once daily at home. The nurse should instruct the client to report which of the following findings immediately?
A. Bruising at injection site
Bruising at injection site is wrong because bruising is a common and expected side effect of enoxaparin therapy, especially if the client is using the same injection site repeatedly. The client should be instructed to rotate the injection sites and apply gentle pressure after each injection to minimize bruising.
B. Redness at injection site
Redness at injection site is wrong because redness is also a common and expected side effect of enoxaparin therapy, as it indicates a local inflammatory response to the medication. The client should be advised to avoid rubbing or scratching the injection site and to apply a cold compress if needed.
C. Swelling in one leg
This is because swelling in one leg could indicate a new or worsening deep vein thrombosis (DVT), which is a serious condition that can lead to pulmonary embolism or other complications. The client should report this finding to the provider immediately and seek medical attention.
D. Mild pain at injection site.
Mild pain at injection site is wrong because mild pain is also a common and expected side effect of enoxaparin therapy, as it reflects the needle insertion and the medication delivery. The client should be reassured that the pain will subside shortly and to use a different injection site for the next dose.
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Full Explanation
This is because swelling in one leg could indicate a new or worsening deep vein thrombosis (DVT), which is a serious condition that can lead to pulmonary embolism or other complications. The client should report this finding to the provider immediately and seek medical attention.
Choice A) Bruising at injection site is wrong because bruising is a common and expected side effect of enoxaparin therapy, especially if the client is using the same injection site repeatedly.
The client should be instructed to rotate the injection sites and apply gentle pressure after each injection to minimize bruising.
Choice B) Redness at injection site is wrong because redness is also a common and expected side effect of enoxaparin therapy, as it indicates a local inflammatory response to the medication.
The client should be advised to avoid rubbing or scratching the injection site and to apply a cold compress if needed.
Choice D) Mild pain at injection site is wrong because mild pain is also a common and expected side effect of enoxaparin therapy, as it reflects the needle insertion and the medication delivery.
The client should be reassured that the pain will subside shortly and to use a different injection site for the next dose.
Normal ranges for enoxaparin therapy are based on the client’s weight, indication, and renal function.
The usual dose for DVT prophylaxis is 40 mg subcutaneously once daily, and the usual dose for DVT treatment is 1 mg/kg subcutaneously every 12 hours.
The client should have regular blood tests to monitor the anti-factor Xa level, which should be between 0.5 and 1.0 IU/mL for DVT prophylaxis and between 0.6 and 1.0 IU/mL for DVT treatment.
The client should also have regular platelet counts to check for heparin-induced thrombocytopenia (HIT), which is a rare but serious complication of enoxaparin therapy that causes a drop in platelets and an increased risk of thrombosis.
The normal platelet count range is 150,000 to 450,000/mm3.
Similar Questions
A client who has atrial fibrillation is prescribed dabigatran etexilate mesylate (Pradaxa). The nurse should instruct the client to report which of the following findings immediately? (Select all that apply.)
A. Unusual bleeding or bruising
Dabigatran etexilate mesylate (Pradaxa) is a medication that prevents blood clots and reduces the risk of stroke in patients with atrial fibrillation. However, it can also cause bleeding as a side effect. Therefore, the nurse should instruct the client to report any signs of unusual bleeding or bruising, blood in urine or stool, or abdominal pain or swelling immediately.These could indicate a serious complication such as gastrointestinal bleeding, hemorrhage, or internal organ damage.
B. Blood in urine or stool
Dabigatran etexilate mesylate (Pradaxa) is a medication that prevents blood clots and reduces the risk of stroke in patients with atrial fibrillation. However, it can also cause bleeding as a side effect. Therefore, the nurse should instruct the client to report any signs of unusual bleeding or bruising, blood in urine or stool, or abdominal pain or swelling immediately.These could indicate a serious complication such as gastrointestinal bleeding, hemorrhage, or internal organ damage.
C. Abdominal pain or swelling
Dabigatran etexilate mesylate (Pradaxa) is a medication that prevents blood clots and reduces the risk of stroke in patients with atrial fibrillation. However, it can also cause bleeding as a side effect. Therefore, the nurse should instruct the client to report any signs of unusual bleeding or bruising, blood in urine or stool, or abdominal pain or swelling immediately.These could indicate a serious complication such as gastrointestinal bleeding, hemorrhage, or internal organ damage.
D. Headache or dizziness
Choice D, headache or dizziness, is not a correct answer. Although these symptoms could be caused by dabigatran, they are not as serious or urgent as bleeding. They could also be due to other factors such as dehydration, low blood pressure, or stress.The nurse should advise the client to monitor these symptoms and seek medical attention if they persist or worsen.
E. Shortness of breath.
Choice E, shortness of breath, is not a correct answer. Shortness of breath is not a common side effect of dabigatran. However, it could be a symptom of atrial fibrillation or its complications such as heart failure or stroke.The nurse should educate the client about the signs and symptoms of these conditions and instruct them to call 911 if they experience chest pain, palpitations, fainting, or weakness.
Full Explanation
Dabigatran etexilate mesylate (Pradaxa) is a medication that prevents blood clots and reduces the risk of stroke in patients with atrial fibrillation.
However, it can also cause bleeding as a side effect.
Therefore, the nurse should instruct the client to report any signs of unusual bleeding or bruising, blood in urine or stool, or abdominal pain or swelling immediately. These could indicate a serious complication such as gastrointestinal bleeding, hemorrhage, or internal organ damage.
Choice D, headache or dizziness, is not a correct answer.
Although these symptoms could be caused by dabigatran, they are not as serious or urgent as bleeding.
They could also be due to other factors such as dehydration, low blood pressure, or stress. The nurse should advise the client to monitor these symptoms and seek medical attention if they persist or worsen.
Choice E, shortness of breath, is not a correct answer.
Shortness of breath is not a common side effect of dabigatran.
However, it could be a symptom of atrial fibrillation or its complications such as heart failure or stroke. The nurse should educate the client about the signs and symptoms of these conditions and instruct them to call 911 if they experience chest pain, palpitations, fainting, or weakness.
The nurse recognizes what absolute contraindication to the administration of a thrombolytic to a patient having an acute myocardial infarction?
A. History of hypertension
Choice A is wrong because history of hypertension is not an absolute contraindication, but a relative one. This means that the benefits of thrombolytic therapy may outweigh the risks in some cases, depending on the severity and duration of hypertension.
B. History of stroke
A history of stroke is an absolute contraindication to the administration of a thrombolytic to a patient having an acute myocardial infarction (AMI). This is because thrombolytics can increase the risk of intracranial hemorrhage and worsen the neurological outcome.
C. History of peptic ulcer disease
Choice C is wrong because history of peptic ulcer disease is also a relative contraindication, not an absolute one. Thrombolytics can increase the risk of gastrointestinal bleeding, but this can be managed with proton pump inhibitors or histamine-2 blockers.
D. History of diabetes mellitus.
Choice D is wrong because history of diabetes mellitus is not a contraindication at all to thrombolytic therapy. In fact, some studies have shown that diabetic patients with AMI may benefit more from thrombolytic therapy than non-diabetic patients.
E. Shortness of breath.
Full Explanation
A history of stroke is an absolute contraindication to the administration of a thrombolytic to a patient having an acute myocardial infarction (AMI). This is because thrombolytics can increase the risk of intracranial hemorrhage and worsen the neurological outcome.
Choice A is wrong because history of hypertension is not an absolute contraindication, but a relative one. This means that the benefits of thrombolytic therapy may outweigh the risks in some cases, depending on the severity and duration of hypertension.
Choice C is wrong because history of peptic ulcer disease is also a relative contraindication, not an absolute one. Thrombolytics can increase the risk of gastrointestinal bleeding, but this can be managed with proton pump inhibitors or histamine-2 blockers.
Choice D is wrong because history of diabetes mellitus is not a contraindication at all to thrombolytic therapy. In fact, some studies have shown that diabetic patients with AMI may benefit more from thrombolytic therapy than non-diabetic patients.
Which patients below would be at a HIGH risk for developing adverse effects of Heparin drug therapy? Select all that apply:
A. A 55-year-old male patient who is post-op day 1 from brain surgery.
Choice A is correct because a patient who is post-op day 1 from brain surgery has a high risk of bleeding from the surgical site or intracranially.Heparin can increase this risk and cause life-threatening hemorrhage. Therefore, this patient should not receive heparin unless absolutely necessary and under strict supervision.
B. A 45-year-old female patient with a pulmonary embolism.
Choice B is wrong because a patient with a pulmonary embolism (PE) is a candidate for heparin therapy. A PE is a blood clot that blocks the blood flow to the lungs and can cause respiratory failure and death.Heparin can prevent the clot from becoming larger and causing more damage, and also prevent new clots from forming. Therefore, this patient would benefit from heparin therapy and is not at a high risk of adverse effects.
C. A 36-year-old male patient with active peptic ulcer disease.
Choice C is correct because a patient with active peptic ulcer disease (PUD) has a high risk of bleeding from the stomach or duodenum. PUD is a condition where the lining of the digestive tract is eroded by stomach acid and bacteria.Heparin can worsen this condition and cause ulcer bleeding or perforation. Therefore, this patient should avoid heparin therapy unless absolutely necessary and under strict supervision.
D. A 43-year-old female with uncontrolled atrial fibrillation.
Choice D is wrong because a patient with uncontrolled atrial fibrillation (AF) is a candidate for heparin therapy. AF is an irregular heartbeat that can cause blood clots to form in the heart chambers and travel to other organs, such as the brain or lungs.Heparin can prevent these clots from forming and reduce the risk of stroke or PE. Therefore, this patient would benefit from heparin therapy and is not at a high risk of adverse effects.
Full Explanation
Heparin is an anticoagulant that inhibits blood clotting and prevents harmful clots from forming in blood vessels. However, heparin can also cause some serious side effects, such as bleeding, bruising, low platelet count, allergic reactions, and osteoporosis.
Therefore, patients who are at a high risk for developing these adverse effects should be monitored closely and have their heparin dose adjusted accordingly.
Choice A is correct because a patient who is post-op day 1 from brain surgery has a high risk of bleeding from the surgical site or intracranially. Heparin can increase this risk and cause life-threatening hemorrhage.
Therefore, this patient should not receive heparin unless absolutely necessary and under strict supervision.
Choice B is wrong because a patient with a pulmonary embolism (PE) is a candidate for heparin therapy.
A PE is a blood clot that blocks the blood flow to the lungs and can cause respiratory failure and death. Heparin can prevent the clot from becoming larger and causing more damage, and also prevent new clots from forming.
Therefore, this patient would benefit from heparin therapy and is not at a high risk of adverse effects.
Choice C is correct because a patient with active peptic ulcer disease (PUD) has a high risk of bleeding from the stomach or duodenum.
PUD is a condition where the lining of the digestive tract is eroded by stomach acid and bacteria. Heparin can worsen this condition and cause ulcer bleeding or perforation.
Therefore, this patient should avoid heparin therapy unless absolutely necessary and under strict supervision.
Choice D is wrong because a patient with uncontrolled atrial fibrillation (AF) is a candidate for heparin therapy.
AF is an irregular heartbeat that can cause blood clots to form in the heart chambers and travel to other organs, such as the brain or lungs. Heparin can prevent these clots from forming and reduce the risk of stroke or PE.
Therefore, this patient would benefit from heparin therapy and is not at a high risk of adverse effects.
Normal ranges of heparin depend on the type of heparin used (unfractionated heparin or low molecular weight heparin), the method of administration (intravenous or subcutaneous), and the indication for use (prophylaxis or treatment). Generally, the therapeutic range for heparin level is 0.3 - 0.7 U/mL, measured by anti-Xa assay. However, this range may vary depending on the pregnancy stage and the type of heparin used. The dose of heparin should be individualized according to the results of suitable laboratory tests and clinical response.