Question

A nurse (PN) is caring for a client who is taking enoxaparin following an orthopedic surgery. Vans should the PN consider prior to administering the next dose? Reference Range: White Blood Cell (WBC) [5,000 to 10,000/mm3 (5 to 10 × 109/L] , Red Blood cell count (RBC) [4.2 to 5.4 × 106/µL (4.2 to 5.4 × 1012/µL], Platelets [150,000 to 400,000/mm3 (150 to 400 × 109/L], Hemoglobin (Hgb) [16 to 18 g/dL (160 to 180 g/L)]

Answer 1

Correct Answers:

Platelet count of 170,000/rnrn3 (170 109fL).

Rationale :

💎Low-molecular-weight heparins (e.g., enoxaparin) can cause heparin-induced thrombocytopenia (HIT), so the most relevant lab to review before dosing is the platelet count.

💎A count of 170,000/mm³ is within the normal range (150–400 × 10⁹/L), indicating no thrombocytopenia and no lab-based reason to hold the next dose.

💎Nurses generally hold and notify the provider if platelets fall below ~100,000/mm³ or drop ≥50% from baseline, but that concern is not present here.

💎While other labs (e.g., WBC, Hgb, RBC) provide clinical context, they do not guide enoxaparin safety the way platelets do.

💎Therefore, with platelets normal, administration may proceed as prescribed while continuing routine bleeding and HIT surveillance.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Low serum zinc level.

Rationale :

🔷 Zinc is essential for growth, tissue repair, and appetite; low serum zinc is a classic biochemical clue for failure to thrive (FTT), especially during nutrition transitions (parenteral → enteral).

🔷 Infants with insufficient intake or malabsorption can become zinc-deficient, leading to poor weight gain, impaired wound healing, and dermatitis, all consistent with FTT.

🔷 During step-down from parenteral to enteral feeds, micronutrient gaps (not just calories) frequently unmask underlying deficits like zinc.

🔷 Recognizing low zinc prompts targeted supplementation and dietetic adjustments to restore adequate growth velocity.

🔷 Close tracking of weight-for-age/length-for-age z-scores alongside zinc repletion helps confirm recovery from FTT.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Denial.

Rationale :

✴ “You must have made a mistake… we want a second opinion” exemplifies Denial, the initial Kübler-Ross stage where reality is too painful to accept.

✴ In Denial, families often seek re-testing or additional opinions as a protective coping strategy.

✴ Therapeutically, the nurse acknowledges feelings, offers clear, factual information, and assesses support needs without forcing rapid acceptance.

✴ Recognizing Denial helps the nurse pace education, avoid argument, and maintain trust.

✴ This foundation allows gradual movement toward information processing and later adaptive coping.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Administer the medication and document the heart rate.

Rationale :

⚫For infants, the apical hold parameter for digoxin is typically <90–100 bpm (age-dependent); a 2-month-old with HR 120 is above the hold threshold.

⚫Digoxin improves contractility and reduces ventricular rate, benefiting infants with cardiac dysfunction when vitals are appropriate.

⚫With an apical HR ≥100 bpm, it is appropriate to give the dose and document the pre-dose heart rate.

⚫Ongoing nursing care includes consistent apical assessments, serum level monitoring (if ordered), and watching for toxicity signs (e.g., vomiting, bradycardia).

⚫Maintaining dose timing and accurate documentation supports safe therapeutic steady state.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Warmth.
Perspiration.

Rationale :

Warmth

🟡Palpation is the correct technique to assess skin temperature, making warmth a directly palpable finding.

🟡Use the dorsum (back) of the hand—it’s more sensitive to temperature changes—and compare bilaterally to detect asymmetry.

🟡Localized warmth suggests inflammation or infection (e.g., cellulitis, phlebitis) along a specific area or vascular pathway.

🟡Generalized warmth may reflect fever, hypermetabolic states (e.g., hyperthyroidism), or environmental heat exposure.

🟡Document site, degree (e.g., mild/moderate/marked), and pattern (localized vs. generalized) to guide diagnostics and interventions.

Perspiration

🟡Moisture is assessed by palpation, so perspiration/diaphoresis is a palpable skin finding indicating autonomic activity.

🟡Diaphoresis can signal fever, pain/anxiety, hypoglycemia, myocardial ischemia, or drug effects, warranting prompt correlation with vital signs.

🟡Check typical moisture sites—hairline, axillae, palms, trunk—and note distribution (focal vs. diffuse) and severity.

🟡Persistent moisture increases risk for skin maceration and breakdown; implement skin protection and cooling/comfort measures as indicated.

🟡Record onset, triggers, and associated symptoms (e.g., dizziness, chest pain) to support clinical decision-making and trend monitoring.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Daily weight.

Rationale :

🔵In heart failure, daily weight is the most sensitive bedside indicator of fluid status, directly reflecting diuretic effectiveness.

🔵A change of ≈1 kg (2.2 lb) over 24 hours suggests ~1 liter of fluid gain/loss, guiding dose titration and dietary counseling.

🔵While BP, urine appearance, and electrolytes inform safety, they lag or are less specific for net volume change.

🔵Same scale, same time, same clothing enhances trend accuracy and clinical decision-making.

🔵Pairing weights with symptom checks (edema, dyspnea) strengthens assessment of decongestion.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Provide the prescribed antibiotics instead of using the candles.

Rationale :

🖍 Ear candling is unsafe and ineffective, posing risks of burns, canal obstruction, and tympanic membrane injury; evidence-based care prioritizes prescribed antibiotics for otitis.

🖍 Culturally responsive nursing includes respectful dialogue while re-patterning harmful practices toward safe, effective therapy.

🖍 The nurse can acknowledge beliefs, explain risks plainly, and offer acceptable, safe adjuncts (e.g., warm compresses, analgesics) without endorsing hazardous methods.

🖍 Clear instructions to complete the antibiotic course support pathogen eradication and prevention of complications.

🖍 This approach honors culture while ensuring patient safety and clinical efficacy.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Describes the priority of antibiotic administration as prescribed.

Rationale :

◼ Meningococcal meningitis is a medical emergency; early, appropriate IV antibiotics are the top priority to reduce mortality and neurologic injury.

◼ A key outcome is the client’s ability to state the urgency and timing of antibiotic therapy, reinforcing adherence.

◼ Nursing care also includes droplet precautions, neuro checks, and supportive measures, but antibiotics remain central.

◼ Prompt therapy decreases bacterial load and limits inflammatory damage in the meninges.

◼ Education on completion of therapy and follow-up supports relapse prevention and public health control.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

The story injury given by the parent differs from the child's.

Rationale :

🔶 Inconsistent or changing injury histories are a high-priority red flag for non-accidental trauma (child abuse).

🔶 Discrepancies suggest the possibility of concealment and warrant focused assessment, documentation, and mandatory reporting per law.

🔶 The nurse prioritizes safety, performs a head-to-toe exam, and uses non-leading, developmentally appropriate questions with the child.

🔶 Accurate time-stamped documentation of statements and findings is crucial for interdisciplinary review.

🔶 Collaboration with the healthcare team and child protection services supports timely protection and care.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

1

Rationale :

✍️After reconstitution, the vial contains 1 g in 2.5 mL

✍️So the concentration = 1000 mg / 2.5 mL = 400 mg/mL.

✍️The ordered dose is 400 mg,

✍️Which equals (400 mg) ÷ (400 mg/mL)

✅1 mL.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

2 :
The nurse (PN) is caring for an infant who is transitioning from parenteral nutrition to enteral repair. Which finding Should the PN recognize is an indication of failure to thrive?

4 :
Prior to giving digoxin the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on his finding, which action should the PN take?

5 :
Which finding(s) can the practical nurse (PN) determine by palpating a client's skin? Select all that apply

6 :
A client with heart failure (HF) is taking a diuretic. While evaluating the effectiveness of the medication regimen assessment is most important for the practical nurse (PN) to monitor?

7 :
A mother intends to use the cultural practice of treating her child's ear infection with special candles. The home health practical nurse (PN) should demonstrate cultural accommodation by making which request?

8 :
The practical nurse (PN) is contributing to a care plan for an adult client with meningococcal meningitis. Which client outcome is indicated for this client?

9 :
The parent of an 8-year-old client tells the practical nurse (PN) that the child fell out of a tree and hurt the arm and shoulder. Which assessment finding should the practical nurse (PN) note as the most significant indicator of possible child abuse?

QLexNursing

2 : The nurse (PN) is caring for an infant who is transitioning from parenteral nutrition to enteral repair. Which finding Should the PN recognize is an indication of failure to thrive?

4 : Prior to giving digoxin the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on his finding, which action should the PN take?

5 : Which finding(s) can the practical nurse (PN) determine by palpating a client's skin? Select all that apply

6 : A client with heart failure (HF) is taking a diuretic. While evaluating the effectiveness of the medication regimen assessment is most important for the practical nurse (PN) to monitor?

7 : A mother intends to use the cultural practice of treating her child's ear infection with special candles. The home health practical nurse (PN) should demonstrate cultural accommodation by making which request?

8 : The practical nurse (PN) is contributing to a care plan for an adult client with meningococcal meningitis. Which client outcome is indicated for this client?

9 : The parent of an 8-year-old client tells the practical nurse (PN) that the child fell out of a tree and hurt the arm and shoulder. Which assessment finding should the practical nurse (PN) note as the most significant indicator of possible child abuse?

2 :
The nurse (PN) is caring for an infant who is transitioning from parenteral nutrition to enteral repair. Which finding Should the PN recognize is an indication of failure to thrive?

4 :
Prior to giving digoxin the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on his finding, which action should the PN take?

5 :
Which finding(s) can the practical nurse (PN) determine by palpating a client's skin? Select all that apply

6 :
A client with heart failure (HF) is taking a diuretic. While evaluating the effectiveness of the medication regimen assessment is most important for the practical nurse (PN) to monitor?

7 :
A mother intends to use the cultural practice of treating her child's ear infection with special candles. The home health practical nurse (PN) should demonstrate cultural accommodation by making which request?

8 :
The practical nurse (PN) is contributing to a care plan for an adult client with meningococcal meningitis. Which client outcome is indicated for this client?

9 :
The parent of an 8-year-old client tells the practical nurse (PN) that the child fell out of a tree and hurt the arm and shoulder. Which assessment finding should the practical nurse (PN) note as the most significant indicator of possible child abuse?