A client is receiving Enoxaparin for the prevention of deep vein thrombosis. Which of the following actions should the nurse take?

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to take is option C: administer the medication into the subcutaneous tissue. Enoxaparin is a low molecular weight heparin that is typically administered subcutaneously, as it is better absorbed and has a more predictable effect when given in this manner. Administering Enoxaparin intramuscularly (option B) can lead to increased risk of bleeding due to inadvertent puncture of blood vessels or injury to underlying structures. Administering it into the deltoid muscle (option D) is also not recommended as this route is typically reserved for vaccines or certain medications with specific requirements for administration. Massaging the injection site after administration (option A) is contraindicated with anticoagulants like Enoxaparin as it can increase the risk of bleeding and bruising at the injection site. Educationally, it is crucial for nurses to understand the appropriate routes of administration for medications to ensure their efficacy and safety for the patient. This knowledge helps prevent medication errors and adverse effects, ultimately promoting optimal patient outcomes.

Correct Answer: A

Rationale: An INR of 4.0 indicates that the client's blood is clotting too slowly, increasing the risk of bleeding. This level is above the therapeutic range for a client on Warfarin therapy. Therefore, the healthcare professional should notify the provider immediately to prevent potential bleeding complications.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) INR of 4.0. Warfarin is an anticoagulant medication that works by inhibiting clotting factors in the blood. The International Normalized Ratio (INR) measures the effectiveness of warfarin in thinning the blood. An INR of 4.0 indicates that the blood is too thin, putting the client at risk of bleeding complications, including hemorrhage. This finding is crucial to report immediately to the provider to prevent potential harm to the client. Option B) Potassium level of 4.5 mEq/L is within the normal range (3.5-5.0 mEq/L) and does not pose an immediate threat to the client's safety in relation to the warfarin prescription. Option C) Sodium level of 140 mEq/L is also within the normal range (135-145 mEq/L) and does not directly impact the client's safety in the context of taking warfarin for atrial fibrillation. Option D) Creatinine level of 1.0 mg/dL is within the normal range (0.6-1.2 mg/dL) and does not specifically indicate a concern related to the warfarin therapy for atrial fibrillation. Educationally, this question highlights the importance of monitoring and understanding the specific laboratory values that are critical for clients on anticoagulant therapy like warfarin. It emphasizes the need for nurses to be vigilant in recognizing abnormal values that can impact the client's safety and prompt reporting to the healthcare provider for appropriate intervention.

Correct Answer: D

Rationale: In the case of a client with depression prescribed Venlafaxine, monitoring for adverse effects is crucial. Venlafaxine is a serotonin-norepinephrine reuptake inhibitor (SNRI) used to treat depression. The correct answer, option D (B and C), is supported by pharmacological knowledge. Dizziness is a common side effect of Venlafaxine due to its impact on neurotransmitters. Decreased libido is also a known adverse effect, affecting the client's quality of life and potentially leading to medication non-compliance. Option A, cough, is not a typical adverse effect of Venlafaxine. It is important for the nurse to differentiate between common side effects of the medication and unrelated symptoms to provide appropriate care. Educationally, understanding the adverse effects of medications is vital for nursing practice. Nurses must monitor clients for potential side effects to ensure safety and efficacy of treatment. This question reinforces the importance of pharmacological knowledge and the need for vigilant monitoring in clinical practice.

Correct Answer: B

Rationale: Grapefruit juice affects carbamazepine metabolism and should be avoided. It can lead to increased levels of the medication, potentially causing toxicity. Monitoring carbamazepine blood levels and the complete blood count (CBC) is essential to ensure the medication's efficacy and safety. Carbamazepine can cause serious adverse effects like Stevens-Johnson syndrome, which can be life-threatening. Therefore, the client should promptly report any rash to the healthcare provider. Additionally, the client should be educated about potential central nervous system (CNS) side effects such as drowsiness or dizziness, and advised to avoid activities requiring alertness until these effects diminish.