The nurse is reviewing new medication orders for a patient who has an epidural catheter for pain relief. One of the orders is for enoxaparin (Lovenox), a low“molecular-weight heparin (LMWH). What is the nurse™s priority action?

Correct Answer: C

Rationale: The nurse's priority action in this situation is to contact the prescriber because LMWHs like enoxaparin should not be given to a patient with an epidural catheter due to the increased risk of bleeding. Giving LMWH to a patient with an epidural catheter can lead to epidural hematoma, a serious complication that can result in permanent paralysis. It is important to clarify this order with the prescriber to ensure patient safety and prevent potential harm.

Correct Answer: C

Rationale: The primary goal of anticoagulant therapy is to prevent the formation of blood clots or thrombi. Anticoagulants work by inhibiting the clotting process in the blood, thereby reducing the risk of clot formation in the blood vessels. This helps to prevent conditions such as deep vein thrombosis, pulmonary embolism, stroke, and other thromboembolic events. Anticoagulants do not dissolve existing clots (thrombus), they work to prevent new clots from forming. So, the main objective of starting anticoagulant therapy in a patient is to prevent the development of thrombi.

Correct Answer: C

Rationale: When taking Nitroglycerine (transdermal), it is recommended to have a nitrate-free interval of at least 10-12 hours to prevent tolerance from developing. Tolerance can occur if the medication is continuously delivered without a break, leading to reduced effectiveness. Therefore, having a nitrate-free interval of 3-4 hours each day helps to maintain the efficacy of Nitroglycerine therapy and prevent tolerance.

Correct Answer: C

Rationale: Apheresis is the process of collecting specific blood components, such as platelets, using a specialized machine. This method allows the donor to donate only the needed component while returning the rest of the blood components back to the donor. In this case, when Jonas is donating platelets only, it is known as an apheresis donation. This process is different from the traditional whole blood donation method where all blood components are collected and separated later in a lab.

Correct Answer: D

Rationale: In pharmacology, when administering Phenytoin, monitoring is crucial to ensure patient safety and effectiveness of treatment. The correct answer, "D) all of the above," is the most appropriate choice because monitoring all aspects listed - behavior, therapeutic blood levels, and for Steven Johnson syndrome - is essential in the care of a patient receiving Phenytoin. Monitoring behavior is important because Phenytoin can impact mood and cognition, so any changes in behavior could indicate a need for dosage adjustment or further evaluation. Monitoring therapeutic blood levels is critical as Phenytoin has a narrow therapeutic range, and levels outside this range can lead to toxicity or lack of efficacy. Monitoring for Steven Johnson syndrome is necessary as it is a severe, though rare, adverse reaction associated with Phenytoin that requires immediate intervention. Options A, B, and C are incorrect on their own because they each address only one aspect of monitoring Phenytoin administration. Focusing solely on behavior, blood levels, or Steven Johnson syndrome would be insufficient and could lead to missed opportunities for intervention or adverse outcomes. In an educational context, understanding the comprehensive monitoring requirements for medications like Phenytoin is vital for nursing students and practicing nurses. It emphasizes the importance of holistic patient care, pharmacological knowledge, and vigilance in recognizing and responding to potential complications. By mastering this concept, nurses can ensure safe medication administration and promote positive patient outcomes in clinical practice.