a nurse is preparing to administer enoxaparin to a client which of the following actions should the nurse plan to take

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment Form A

1. A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse plan to take?

A. Aspirate for a blood return before depressing the plunger
B. Insert the needle at a 45-degree angle
C. Administer the medication 2.54 cm (1 in) from the umbilicus
D. The nurse should not expel the air bubble in the prefilled syringe

Correct answer: D

Rationale: The correct action when administering enoxaparin is not to expel the air bubble in the prefilled syringe. Expelling the air bubble may lead to the loss of medication and result in an incomplete dose. Aspirating for a blood return (Choice A) is not necessary for subcutaneous injections like enoxaparin. Inserting the needle at a 45-degree angle (Choice B) is not specific to administering enoxaparin. Administering the medication 2.54 cm (1 in) from the umbilicus (Choice C) is not a standard guideline for enoxaparin administration.

2. What is the priority action for a patient with a fever?

A. Administer an antipyretic medication as prescribed.
B. Assess the patient's temperature regularly.
C. Provide cooling measures such as a cool compress.
D. Provide the patient with blankets for comfort.

Correct answer: B

Rationale: The priority action when a patient has a fever is to assess the patient's temperature regularly. Monitoring the temperature helps track the effectiveness of interventions and detect any worsening fever. Administering antipyretic medication (Choice A) should be done based on healthcare provider's orders after assessing the patient's condition. While providing cooling measures such as a cool compress (Choice C) can help reduce fever, assessing the temperature takes precedence. Providing blankets for comfort (Choice D) is not the priority when dealing with a fever.

3. A client who reports insomnia is being taught by a nurse about promoting rest and sleep. Which statement should indicate to the nurse that the client understands the instructions?

A. I will walk briskly for 30 minutes before bedtime
B. I will have a cup of hot cocoa immediately before bedtime
C. I will no longer have a glass of wine before bedtime
D. I will do my muscle relaxation techniques each afternoon

Correct answer: C

Rationale: The correct answer is C because avoiding alcohol before bedtime can help promote better sleep. Choice A is incorrect as vigorous exercise close to bedtime can actually hinder sleep. Choice B is also incorrect as consuming beverages with caffeine or sugar close to bedtime can disrupt sleep. Choice D, while a good practice, does not directly address the issue of avoiding alcohol before bedtime to improve sleep quality.

4. A healthcare provider is reviewing the medical record of a client who has a new prescription for cimetidine. Which of the following laboratory findings should the healthcare provider identify as the priority to report to the provider?

A. Sodium 140 mEq/L
B. WBC count 9,000/mm3
C. Aspartate aminotransferase (AST) 50 units/L
D. Fasting glucose 105 mg/dL

Correct answer: C

Rationale: An elevated AST level is indicative of liver damage, which is the priority finding to report to the provider when administering cimetidine. Elevated liver enzymes can be a sign of liver toxicity or damage. Monitoring liver function is crucial when using cimetidine, as it can sometimes lead to hepatotoxicity. The other laboratory findings are within normal ranges and not directly associated with cimetidine administration.

5. What are the key components of a pain assessment in a postoperative patient?

A. Checking the effectiveness of pain interventions
B. Observing for nonverbal signs of pain like grimacing
C. Assessing the location, duration, and quality of the pain
D. Asking the patient to rate their pain on a scale of 1-10

Correct answer: A

Rationale: The correct answer is A because in a postoperative patient, it is crucial to evaluate the effectiveness of the pain interventions that have been implemented. While choices B, C, and D are important aspects of a pain assessment, they do not specifically address the key component of assessing the effectiveness of the interventions applied postoperatively.