Nursing Elites

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

• A. Gently rub the injection site after removing the needle
• B. Have the client maintain a side-lying position for at least five minutes
• C. Remove the needle and engage the needle safety device
• D. Apply heat to the injection site

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 Rubbing the injection site after the needle is withdrawn is not recommended as it may cause irritation and bruising.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. A nurse at an outpatient clinic is returning phone calls that have been made to the clinic. Which of the following calls should have the highest priority for medical intervention?

• A. A home health patient reports, "I am starting to have a breakdown of my heels."?
• B. A patient that received an upper extremity cast yesterday reports, "I can't feel my fingers in my right hand today."?
• C. A young female reports, 'I think I sprained my ankle about 2 weeks ago.'
• D. A middle-aged patient reports, 'My knee is still hurting from the TKR.'

Correct answer: B

Rationale: The correct answer is the patient who received an upper extremity cast yesterday and reports not being able to feel their fingers in the right hand. This situation indicates a potential neurovascular issue that requires immediate attention to prevent complications. The other options are of lesser priority: A - Breakdown of the heels, while concerning, is not an acute issue that necessitates immediate intervention. C - An ankle sprain that occurred two weeks ago is now subacute and unlikely to be an urgent medical concern. D - Pain in the knee following a total knee replacement (TKR) is common in the early postoperative period and is not unexpected.

3. Clomiphene is prescribed for a female client to treat infertility. The nurse is providing information to the client and her spouse about the medication and provides the couple with which information?

• A. If the oral tablets are not successful, the medication will be administered intravenously.
• B. The couple should engage in coitus at least every other day during treatment.
• C. The physician should be notified immediately if breast engorgement occurs.
• D. Multiple births occur in a small percentage of clomiphene-facilitated pregnancies.

Correct answer: D

Rationale: The correct answer is that multiple births (usually twins) occur in a small percentage (8% - 10%) of clomiphene-facilitated pregnancies. The couple should be informed about this potential outcome. Clomiphene is available in 50-mg tablets for oral use; there is no intravenous form of the medication. Breast engorgement is a common side effect of clomiphene that typically resolves after discontinuation of the medication. Ovulation usually happens 5 to 10 days after the last dose of clomiphene, and the couple is advised to engage in coitus at least every other day during this time. Therefore, choices A, B, and C are incorrect as they do not provide accurate information regarding clomiphene treatment for infertility.

4. The nurse is caring for a client who is 28 weeks pregnant and complains of swollen hands and feet. Which symptom below would cause the greatest concern?

• A. Nasal congestion
• B. Hiccups
• C. Blood glucose of 150
• D. Muscle spasms

Correct answer: D

Rationale: The correct answer is muscle spasms because they can be indicative of a severe condition like preeclampsia, which is a serious complication during pregnancy characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys. Nasal congestion and hiccups are common discomforts during pregnancy and do not pose a severe risk to the client or fetus. A blood glucose level of 150, while slightly elevated, may not be alarming in a pregnant individual and can be managed through dietary modifications or medication adjustments. Muscle spasms, especially in the context of pregnancy, should be taken seriously and thoroughly assessed to rule out any underlying serious conditions.

5. A nurse is caring for a client with an elevated urine osmolarity. The nurse should assess the client for:

• A. fluid volume excess.
• B. hyperkalemia.
• C. hypercalcemia.
• D. fluid volume deficit.

Correct answer: D

Rationale: Elevated urine osmolarity indicates that the urine is concentrated, suggesting the body is trying to conserve water. This commonly occurs in conditions like dehydration or fluid volume deficit. Assessing the client for fluid volume excess, hyperkalemia, or hypercalcemia would not be the priority in this situation. Therefore, the correct answer is to assess the client for fluid volume deficit. Fluid volume excess is characterized by decreased urine osmolarity, while hyperkalemia and hypercalcemia are related to electrolyte imbalances and would not directly cause elevated urine osmolarity.

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