Nursing Elites

1. A client is being taught about the use of enoxaparin (Lovenox) for the prevention of deep vein thrombosis. Which instruction should the nurse include in the teaching plan?

• A. Inject the medication subcutaneously.
• B. Avoid massaging the injection site after administration.
• C. Administer the medication at the same time each day.
• D. Do not expel the air bubble from the syringe before injection.

Correct answer: C

Rationale: Enoxaparin (Lovenox) is administered subcutaneously at the same time each day to maintain consistent blood levels. Injecting the medication into the muscle is incorrect, as it should be given subcutaneously. Massaging the injection site should be avoided to prevent bruising. The air bubble in the prefilled syringe should not be expelled, as it ensures the full dose is administered.

2. A client who received a kidney transplant is taking azathioprine (Imuran), and the nurse provides instructions about the medication. Which statement by the client indicates a need for further instructions?

• A. I need to watch for signs of infection.
• B. I need to discontinue the medication after 14 days of use.
• C. I can take the medication with meals to minimize nausea.
• D. I need to call the health care provider (HCP) if more than one dose is missed.

Correct answer: B

Rationale: Azathioprine is an immunosuppressant taken for life. Discontinuing the medication after 14 days is incorrect.

3. The client has begun medication therapy with pancrelipase (Pancrease MT). The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed?

• A. Weight loss
• B. Relief of heartburn
• C. Reduction of steatorrhea
• D. Absence of abdominal pain

Correct answer: C

Rationale: Pancrelipase (Pancrease MT) is a pancreatic enzyme replacement therapy used to aid digestion in clients with pancreatic insufficiency. One of the key goals of pancrelipase therapy is to reduce the amount of undigested fat in the stool, known as steatorrhea. Therefore, the nurse should evaluate the effectiveness of pancrelipase by looking for a reduction in steatorrhea, indicating improved digestion and absorption of fats.

4. A client has been prescribed furosemide (Lasix), and the nurse is monitoring for adverse effects associated with this medication. Which of the following should the nurse recognize as a potential adverse effect? Select one that doesn't apply.

• A. Nausea
• B. Tinnitus
• C. Hypotension
• D. Hypokalemia

Correct answer: A

Rationale: Furosemide is a loop diuretic that can lead to adverse effects such as tinnitus, hypotension, and hypokalemia. While nausea is a common side effect of many medications, it is not typically associated with furosemide. Therefore, the nurse should recognize nausea as a potential adverse effect that doesn't apply to furosemide.

5. Mafenide acetate (Sulfamylon) is prescribed for a client with a burn injury. When applying the medication, the client complains of local discomfort and burning. Which of the following is the most appropriate nursing action?

• A. Notifying the registered nurse
• B. Discontinuing the medication
• C. Informing the client that this is normal
• D. Applying a thinner film than prescribed to the burn site

Correct answer: C

Rationale: The correct action is to inform the client that local discomfort and burning are normal reactions to Mafenide acetate. This medication is used to treat burns by reducing bacteria in avascular tissues. Discontinuing the medication or applying a thinner film than prescribed is not necessary or recommended in this situation.

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