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Questions 149

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Extract:


Question 1 of 5

The nurse is preparing to administer a dose of enoxaparin (Lovenox) to a client with a pulmonary embolism. Which of the following actions by the nurse is correct?

Correct Answer: C

Rationale: enoxaparin is administered subcutaneously in the abdomen, at least 2 inches from the umbilicus, without aspiration or massage

Question 2 of 5

A client with heart failure has a left ventricular ejection fraction of 38%. When educating the client about managing the condition, which of the following advice should the nurse include? Select all that apply.

Correct Answer: A,B,D

Rationale: Rest periods (
A), avoiding strenuous activities (
B), and stopping smoking (
D) manage heart failure. All exercise (
C) is not stopped; moderate activity is encouraged. Alcohol should be minimal, not 2-3 drinks (E).

Question 3 of 5

A client with a tracheostomy is exhibiting difficulty breathing, and respirations are increasingly noisy. Secretions are very thick. Which of the following initial interventions is most indicated?

Correct Answer: A

Rationale: Thick secretions causing noisy respirations and breathing difficulty indicate the need for increased humidification to thin secretions and suctioning to clear the tracheostomy tube (
A). Notifying the physician (
B) or encouraging coughing (
C) is secondary, and irrigation (
D) is not typically the initial step.

Question 4 of 5

The physician has ordered an infusion of Osmitrol (mannitol) for a client with increased intracranial pressure. Which finding indicates the direct effectiveness of the drug?

Correct Answer: B

Rationale: Mannitol is an osmotic diuretic that reduces intracranial pressure by increasing urinary output, drawing fluid out of the brain tissue.

Question 5 of 5

The nurse is caring for the client following a thyroidectomy when suddenly the client becomes nonresponsive and pale, with a BP of 60 systolic. The nurse's initial action should be to:

Correct Answer: B

Rationale: Increasing normal saline infusion addresses hypovolemic shock, likely due to post-thyroidectomy hemorrhage, as the priority action.

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