after injecting enoxaparin lovenox subcutaneously into the abdomen which action should the nurse take
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Nursing Elites

NCLEX-PN

Kaplan NCLEX Question of The Day

1. After administering enoxaparin (Lovenox) subcutaneously into the abdomen, which action should the nurse take?

Correct answer: C

Rationale: After administering a subcutaneous injection of enoxaparin (Lovenox) into the abdomen, the nurse should remove the needle and engage the needle safety device. Rubbing the injection site after the needle is withdrawn is not recommended as it may cause irritation and bruising. Having the client maintain a side-lying position for at least five minutes is unnecessary for a subcutaneous injection into the abdomen. Applying heat to the injection site is not indicated after administering enoxaparin subcutaneously; it could increase the risk of bleeding or bruising at the injection site.

2. Which of the following microorganisms is easily transmitted from client to client on the hands of healthcare workers?

Correct answer: C

Rationale: The correct answer is staphylococcus aureus. Staphylococcus aureus microorganisms are ubiquitous and easily transmitted by healthcare workers who fail to conduct routine hand washing between clients. Staphylococcus aureus can reside on the skin and be transferred from one client to another if proper hand hygiene is not practiced. Mycobacterium tuberculosis is mainly transmitted through the airborne route, clostridium tetani is usually acquired through exposure to soil or dirt contaminated with tetanus spores, and human immunodeficiency virus is not easily transmitted through casual contact or on the hands of healthcare workers.

3. Metformin (Glucophage) is administered to clients with type II diabetes mellitus. Metformin is an example of:

Correct answer: A

Rationale: Metformin is classified as an antihyperglycemic agent because it works by reducing hepatic glucose output and decreasing glucose absorption from the gut, thereby preventing hyperglycemia. Choice B, a hypoglycemic agent, is incorrect as hypoglycemic agents stimulate insulin production, which is not the mechanism of action of metformin. Choice C, an insulin analogue, is incorrect as metformin is not a type of insulin but a distinct medication. Choice D, a pancreatic alpha cell stimulant, is incorrect as metformin does not stimulate any pancreatic cells, but rather acts on the liver and gut to lower blood sugar levels.

4. The nurse has just received a change-of-shift report. Which client should the nurse assess first?

Correct answer: A

Rationale: The nurse should assess the client 2 hours post-lobectomy with 150cc drainage first because postoperative assessments are crucial during the immediate postoperative period. This client may be at higher risk for complications, such as bleeding or infection, requiring immediate attention. Clients in choices B, C, and D are relatively stable and can be assessed after the immediate postoperative client has been evaluated.

5. When caring for a client with a possible diagnosis of placenta previa, which of the following admission procedures should the nurse omit?

Correct answer: B

Rationale: The correct answer is 'enema.' Administering an enema to a client with placenta previa can dislodge the placenta, leading to an increased risk of bleeding and complications. It is crucial to avoid any interventions that may disrupt the placenta's positioning. Collecting urine and blood specimens are necessary for diagnostic purposes and monitoring, while a perineal shave is a routine procedure that does not pose a risk to the client with placenta previa.

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