Selective estrogen receptor modulators (eg, 

tamoxifen) have differential action in different

tissues (mixed agonist/antagonist).  In the breast, they block estrogen (antagonist) and are
therefore helpful in inhibiting the growth of estrogen-receptive breast cancer cells.
However, tamoxifen has estrogen-stimulating (agonist) activity in the uterus, resulting in
excessive endometrial proliferation (endometrial hyperplasia).  This hyperplasia can eventually
lead to cancer.  Irregular or excessive menstrual bleeding in premenopausal woman or any
bleeding in postmenopausal women can be a sign of endometrial cancer (Option 3).  Due to its
estrogen-agonist actions, tamoxifen also poses a risk for thromboembolic events (eg, stroke,
pulmonary embolism, deep vein thrombosis).
Clients with breast cancer take tamoxifen for several (5-10) years to prevent recurrence. 
Therefore, monitoring for life-threatening side effects is very important.
(Options 1 and 4)  Because tamoxifen blocks estrogen receptors, it can cause symptoms of
menopause.  Vaginal dryness, hot flashes, and decreased libido (sexual dysfunction) are common
and would be discussed after addressing more concerning symptoms.
(Option 2)  Tamoxifen is not associated with significant immunosuppression although it may
rarely cause leukopenia.
Educational objective:
Tamoxifen has mixed agonist and antagonist activity on estrogen receptors in various tissues.  It
is used for several years in estrogen-responsive breast cancer.  However, it is associated with
increased risk of endometrial cancer and venous thromboembolism.  Menopausal symptoms (eg,
vaginal dryness, hot flashes) are the most common side effect.
A potential complication of chemotherapy is acute tumor lysis syndrome (TLS), a rapid release
of intracellular components into the bloodstream.  Massive cell lysis releases intracellular ions
(potassium and phosphorus) and nucleic acids into the bloodstream.  Catabolism of the nucleic
acids produces uric acid, resulting in severe hyperuricemia.  Released phosphorus binds
calcium, producing calcium phosphate mixture but lowering serum calcium levels.  Both calcium
phosphate and uric acid are deposited into the kidneys, causing renal injury.
Allopurinol (Zyloprim) blocks the nucleic acid catabolism and prevents hyperuricemia but would
not affect potassium, phosphate, and calcium levels.  Chronic gout and uric acid calculi also
require the administration of allopurinol to decrease uric acid accumulation.  A normal blood
uric acid level for an adult male is 4.4–7.6 mg/dL (262–452 µmol/L) and female is 2.3-6.6
mg/dL (137-393 µmol/L).
(Option 1)  The normal calcium level for adults is 8.6–10.2 mg/dL (2.15–2.55 mmol/L).  The
client with this complication would experience hypocalcemia.
(Option 2)  The normal phosphate level for adults is 2.4–4.4 mg/dL (0.78–1.42 mmol/L).  In this
condition, the phosphate level would show hyperphosphatemia.
(Option 3)  The normal potassium level for adults is 3.5–5.0 mEq/L (3.5–5.0 mmol/L). 
Hyperkalemia is usually present in a client with this chemotherapy-induced complication.
Educational objective:
The therapeutic effect of allopurinol (Zyloprim) is to decrease hyperuricemia caused by TLS. 
Laboratory values of significance in TLS include rising blood uric acid, potassium, and
phosphate levels, with decreasing calcium levels.

The emergency department nurse prepares a male client for surgery.  The client was admitted
with a traumatic open fracture of the femur, hematocrit of 36% (0.36), and hemoglobin of 12
g/dL (120 g/L).  Which prescription should the nurse validate with the health care provider
before administration?

The Joint Commission Surgical Improvement Project CORE measure set has shown that
preventives (eg, heparin, enoxaparin, aspirin) in select surgical procedures, given 24 hours before
and after surgery, reduce the risk of venous thromboembolism.  However, the estimated blood
loss in a client with a fracture can be significant depending on the site (eg, 250-1200 mL). 
Although this client's admission hematocrit (36% [0.36]) and hemoglobin (12 g/dL [120 g/L])
are only slightly low for an adult male (normal: 39%-50% [0.39-0.50], 13.2-17.3 g/dL [132-173
g/L]), the blood loss may not yet be evident.  Therefore, the nurse would validate the prescription
for enoxaparin (Lovenox) with the health care provider before administration.
Medications commonly prescribed for a client with an open fracture include:
  Cefazolin (Ancef), a bone-penetrating cephalosporin antibiotic that is active against skin
flora (Staphylococcus aureus); it is given prophylactically before and after surgery to
prevent infection (Option 1)
 Cyclobenzaprine (Flexeril), a central and peripheral muscle relaxant given to treat pain
associated with muscle spasm; carisoprodol (Soma) or methocarbamol (Robaxin) can
also be prescribed
 Tetanus and diphtheria toxoid, an immunization given prophylactically to prevent
infection (Clostridium tetani) if immunizations are not up to date (>10 years),
unavailable, or unknown (Option 4)
 Ketorolac (Toradol), a nonsteroidal anti-inflammatory drug given to decrease
inflammation and pain
 Opioids (eg, morphine, hydrocodone [Vicodin]), given for analgesia (Option 3)
Educational objective:
Medications commonly prescribed for a client with an open fracture to prevent infection and
treat pain and muscle spasm include cefazolin (Ancef), tetanus toxoid, ketorolac (Toradol),
opioids, and cyclobenzaprine (Flexeril).

Tamoxifen is a selective estrogen receptor modulator that is prescribed to treat certain types of
breast cancer and to prevent breast cancer recurrence.  Tamoxifen works by blocking
estrogen receptors in certain estrogen-sensitive tissues (eg, breast, vagina), but it also increases
affinity for estrogen in some tissues, such as the uterus.  In the treatment of breast cancer,
tamoxifen inhibits growth of estrogen receptor–positive tumors.
Clients typically take tamoxifen for several (eg, 5-10) years after treatment to prevent breast
cancer recurrence.  Common side effects of tamoxifen therapy, like the effects typically seen in
menopause (eg, hot flashes, vaginal dryness, menstrual irregularities), are related to decreased
estrogen.  Follow-up would be required for clients with symptoms or a history of tamoxifen's
most serious side effects, including:
 Thromboembolic events (eg, deep venous thrombosis, pulmonary embolism,
stroke) (Option 3)
 Endometrial cancer (eg, abnormal vaginal bleeding)
(Options 1, 2, and 4)  Shellfish and peanut allergies, previous smoking history, and history of
depression are not contraindications for treatment with tamoxifen.
Educational objective:
Tamoxifen is a selective estrogen receptor modulator prescribed for the treatment and prevention
of estrogen receptor–positive breast cancers.  Serious side effects include thromboembolic events
(eg, deep venous thrombosis) and endometrial cancer.

A client with chronic kidney disease has received a continuous intravenous infusion of heparin
for 5 days.  The nurse reviews the coagulation studies and the medication administration record. 
Which prescription would the nurse question?  Click on the exhibit button for additional
information.
Vitamin K (phytonadione) is a fat-soluble vitamin that is administered as an antidote for
warfarin-related bleeding.  This medication prescription should be questioned as vitamin K
reverses the anticoagulant effect of warfarin, and the client's coagulation studies are in the
therapeutic range (aPTT 46-70 sec, INR 2-3).
(Option 1)  Epoetin (Procrit) is a synthetic hormone that stimulates the production of
erythropoietin and is used to treat anemia associated with chronic kidney disease.  This is an
appropriate prescription.
(Option 2)  Sodium polystyrene sulfonate (Kayexalate) is a sodium exchange resin administered
to reduce elevated serum potassium levels in clients with chronic kidney disease and
hyperkalemia.  This is an appropriate prescription for this client.
(Option 4)  Warfarin (Coumadin) is a vitamin K antagonist used for long-term anticoagulation
that is started about 5 days before a continuous heparin infusion is discontinued.  An overlap of
the parenteral and oral anticoagulant is required for about 5 days as this is the time it takes
warfarin to reach therapeutic level.  This is an appropriate prescription for this client.
Educational objective:
Anticoagulants stop thrombus formation by interfering with the coagulation cascade.  Parenteral
heparin and oral warfarin affect the clotting cascade differently; therefore, a 5-day overlap for
the 2 drugs is required.  This allows warfarin to reach a therapeutic level before the continuous
heparin infusion is stopped.

A client with cancer is to receive a third dose of cisplatin.  The client's laboratory results are
shown in the exhibit.  Which factor would be important for the nurse to assess before confirming
the dose with the health care provider?  Click on the exhibit button for additional
information.

Urine output is a good indicator of renal function.  Cisplatin is an antineoplastic medication that
can cause renal toxicity.  The client's elevated BUN (normal 6-20 mg/dL [2.1-7.1 mmol/L]) may
be due to dehydration (prerenal disease) or decreased kidney function.  The creatinine is also
elevated (normal 0.6-1.3 mg/dL [53-115 µmol/L]), an indication of kidney injury.  In addition to
laboratory results, the health care provider will also need to know urine output.  The medication
dosage may then be adjusted or discontinued.
(Option 1)  Blood pressure may be part of the assessment of kidney function, but multiple
disorders can cause changes in blood pressure.  Urine output is a better indicator of renal
function.
(Option 2)  Capillary refill is used to assess the circulatory system and is not a good indicator of
a decrease in renal function.
(Option 3)  Skin turgor is important in assessing hydration status.  However, this client's
laboratory results indicate the possibility of renal toxicity from the cisplatin.  Urine output is a
better indicator of renal function.
Educational objective:
 Cisplatin is an antineoplastic drug that may cause kidney injury.  Assessment of renal function
includes laboratory values and urine output.

Factor Xa inhibitors (eg, rivaroxaban [Xarelto], edoxaban, apixaban) are anticoagulants used

to prevent and treat venous thromboembolism.  Factor Xa inhibitors are being prescribed more
frequently than other oral anticoagulants (eg, warfarin), as they have a lower risk of bleeding and
require less ongoing monitoring (eg, PT/INR).
Clients prescribed rivaroxaban should be educated to avoid taking over-the-counter medications
or supplements that increase bleeding risk, such as NSAIDs (eg, aspirin), garlic, and ginger. 
The combined effects of rivaroxaban and other anticoagulants may greatly increase the risk of
uncontrolled bleeding (eg, epidural, intracranial, gastrointestinal) and hemorrhage (Option 3).
(Option 1)  Unlike warfarin, factor Xa inhibitors are not affected by vitamin K, which is found
in many green, leafy vegetables (eg, spinach, kale).
(Option 2)  Anticoagulants, particularly factor Xa inhibitors, increase the risk for spontaneous
intracranial bleeding or formation of epidural hematomas.  Clients taking factor Xa inhibitors
should be instructed to immediately contact their health care provider for symptoms of
neurological impairment (eg, extremity weakness, altered sensation, numbness).
(Option 4)  Routine monitoring of clotting times (eg, PT/INR, PTT) is unnecessary for clients
prescribed factor Xa inhibitors.
Educational objective:
The nurse should instruct clients receiving factor Xa inhibitors (eg, rivaroxaban, edoxaban,
apixaban), which are anticoagulants, to avoid taking additional medications or supplements with
anticoagulant effects (eg, NSAIDs, garlic, ginger).  The combined anticoagulant effects increase
the risk for uncontrolled bleeding and hemorrhage.

Glycoprotein (GP) IIb/IIIa receptor inhibitors (eg, abciximab, eptifibatide, tirofiban) are used
as platelet inhibitors to prevent the occlusion of treated coronary arteries during percutaneous
coronary intervention procedures and prevent acute ischemic complications.  GP IIb/IIIa receptor
inhibitors can cause serious bleeding.  The nurse should closely monitor the client for any
bleeding at the groin puncture site after the percutaneous coronary intervention (Option 1).
The nurse should check the client's baseline complete blood count (eg, hemoglobin, platelet
count).  Some clients may develop serious thrombocytopenia within a few hours, further
increasing the bleeding risk (Option 2).  Hypotension, tachycardia, changes in heart rhythm,
blood in the urine, abdominal/back pain, mental status changes, and black tarry stools may also
indicate internal bleeding and should be monitored carefully when GP IIb/IIIa receptor inhibitors
are administered (Options 4 and 5).
(Option 3)  During and after the infusion of GP IIb/IIIa receptor inhibitors, no traumatic
procedures (initiation of IV sites, intramuscular injections) should be performed unless
absolutely necessary due to the risk of bleeding.
Educational objective:
Glycoprotein IIb/IIIa receptor inhibitors (eg, abciximab, eptifibatide, tirofiban) inhibit platelet
aggregation and increase bleeding risk.  Serious thrombocytopenia can occur within few hours,
further increasing bleeding risk.  After administration, the nurse should monitor the client's blood
counts, blood pressure, and heart rate and rhythm, as well as watch for signs of bleeding.
The nurse is preparing to admit a client with endometrial cancer to the oncology unit for
brachytherapy via a sealed cervical implant.  Which of the following interventions are
appropriate to include in the plan of care for this client?  Select all that apply.

NCLEX® CHANGE AS OF 2017 - Please note that select-all-that-apply (SATA) questions

on NCLEX can now include any number of correct responses.  Only ONE option or up to
ALL options may be correct.  UWorld questions now reflect this change.  Visit NCSBN®
NCLEX FAQs for more information.
Brachytherapy is an internal radiation treatment that is ingested, injected into the bloodstream,
or implanted (eg, seeds, wires) directly into or near the tumor.  Clients with permanent
brachytherapy implants emit low doses of radiation over an extended time period and typically
do not pose a risk of radiation exposure to others.  However, those with temporary
brachytherapy (eg, sealed cervical radium implants) require safety precautions because
the client emits radiation while the source is in place and poses a risk of exposure to others.
The plan of care for a client with temporary brachytherapy implants should include the following
interventions:
 Use appropriate shielding (eg, place client in a lead room, use lead shields and apron) to
limit exposure (Option 1)
 Limit each person's time of exposure to the client (eg, cluster care, 30 minutes per
shift) (Option 2)
 Assign all staff members involved in the client's care their own dosimeter badge to
measure radiation exposure, and instruct them to wear it during every shift (Option 3)
 Instruct the client to remain on bed rest, and use caution when repositioning to avoid
device dislodgement (Option 4)
 Maximize distance from the client (eg, 6 ft [1.8 m] is recommended) (Option 5)
Educational objective:
To avoid radiation exposure from temporary brachytherapy implants, caregivers and visitors
should limit time in the client's room, maximize distance from the client, and use appropriate
shielding.  The client should remain on bed rest and use caution when repositioning, and all staff
members should wear their own dosimeter badge.

TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade], adalimumab [Humira])

block the action of TNF, a mediator that triggers a cell-mediated inflammatory response in the
body.  These drugs reduce the manifestations of rheumatoid arthritis (RA) and slow the
progression of joint damage by inhibiting the inflammatory response.  The medication
causes immunosuppression and increased susceptibility for infection and malignancies.
Clients should have a baseline TST before initiating therapy and yearly skin tests thereafter. 
Those with latent tuberculosis (TB) must be treated with antitubercular agents before initiating
treatment with these drugs.  Otherwise, TB reactivation would occur (Option 4).
(Option 1)  CRP is a non-specific test used to detect acute or chronic inflammation in the body. 
CRP can be used to evaluate the effectiveness of medications that decrease inflammation.  An
elevation would be expected in clients with RA, especially during a flare, but it is not the most
important test result to check before initiating therapy.
(Options 2 and 3)  LDL cholesterol and PT are unrelated to the administration of these
medications.
Educational objective:
Major adverse effects of biologic disease-modifying TNF inhibitor drugs (eg, etanercept,
infliximab, adalimumab) include severe infections and bone marrow suppression.  TB
reactivation is a major concern.  Therefore, all clients must receive a TST to rule out latent TB.
Heparin is a natural anticoagulant.  Its risk is heparin-induced thrombocytopenia (HIT), also
known as heparin-associated thrombocytopenia.  Normal platelet range is
150,000-400,000/mm3 (150-400 x 109/L).  A mild lowering of platelets may occur and resolve
spontaneously around the 4th day of administration.  The danger is type II HIT, a more severe
form in which there is an acute drop in the number of platelets (more than 50% from baseline),
which requires discontinuing heparin (Option 1).
Angiotensin-converting enzyme (ACE) inhibitors such as lisinopril are teratogenic.  Lisinopril
can cause embryonic/fetal developmental abnormalities (cardiovascular and central nervous
system) if taken during pregnancy, especially during the first 13 weeks of gestation.  During the
2nd and 3rd trimesters, ACE inhibitors interfere with fetal renal hemodynamics, resulting in low
fetal urine output (oligohydramnios) and fetal growth restriction (Option 2).
Nitroglycerine causes vasodilation and can lower blood pressure.  Systolic blood pressure
should be >90 mm Hg to ensure renal perfusion (Option 3).
(Option 4)  Gingival hyperplasia or hypertrophy is a known side effect of phenytoin (Dilantin)
and is not a reason to stop the drug.  Vigorous dental hygiene beginning within 10 days of
initiation of phenytoin therapy can help control it.  Signs and symptoms that require
discontinuation include toxic levels or phenytoin hypersensitivity syndrome (fever, skin rash,
and lymphadenopathy).
(Option 5)  Warfarin (Coumadin) is used to prolong clotting so that the desired result is a
"therapeutic" range rather than the client's "normal" control value when not on the drug. 
Therapeutic range is considered roughly 1.5-2.5 times the control (International Normalized
Ratio [INR] of 2-3), but up to 3-4 times the control (INR of 2.5-3.5) in high-risk situations such
as an artificial heart valve.
Educational objective:
Heparin should be held when there is significant thrombocytopenia.  Angiotensin-converting
enzyme inhibitors are not administered to pregnant women, and nitrates are not administered
when a client is hypotensive.  Prothrombin time/International Normalized Ratio is expected to be
1.5-2.5 (up to 4) times the control value when therapeutic effects are reached.  Gingival
hyperplasia is a side effect of phenytoin (Dilantin) administration and is not a reason to stop the
drug.
 Gingival hyperplasia

Ferrous sulfate is an oral iron supplement prescribed to prevent or treat iron deficiency

anemia, which occurs when the body lacks sufficient iron, an essential mineral in the formation
of new RBCs.  Low iron levels may result from malabsorption, insufficient intake, increased
requirements (eg, pregnancy), or blood loss.  The nurse should avoid administering calcium
supplements or antacids with or within 1 hour of ferrous sulfate because calcium decreases
iron absorption (Option 4).
(Option 1)  Taking an iron supplement increases the client's risk for constipation.  Instructing the
client to increase fluid intake during therapy may help prevent hard stools.
(Options 2 and 3)  Taking an iron supplement with vitamin C (eg, orange juice) further
enhances duodenal acidity and increases absorption.  An acid-rich environment enhances iron
absorption, so oral supplements should be taken 1 hour before or 2 hours after meals.
Educational objective:
Ferrous sulfate is an oral iron supplement prescribed to prevent or treat iron deficiency anemia. 
The nurse should administer the medication 1 hour before or 2 hours after meals because it is
best absorbed in an acidic environment.  Antacids or calcium supplements decrease absorption of
iron if administered with or within 1 hour of ferrous sulfate.

Chemotherapy can cause suppression of rapidly reproducing cells, including bone marrow

suppression.  This can result in decreased red blood cells, white blood cells, and platelets, all
manufactured in the bone marrow.  It is most likely to be seen with chemotherapy (versus
radiation), with the lowest counts (the nadir) usually at 7-10 days after therapy initiation. 
Leukopenia is a decrease in total circulating white blood cell count (<4,000/mm 3) and
neutropenia is a decrease in circulating neutrophils (usually <1500/mm3).
Filgrastim (Neupogen) and pegfilgrastim (Neulasta) stimulate neutrophil production and are
given prophylactically or if the client has an infection and more neutrophils are needed to fight
it (Option 3).
(Option 1)  Cancer chemotherapy causes cell lysis, which results in tumor lysis syndrome due
to massive release of nucleic acid and its metabolic product, uric acid.  Uric acid deposition leads
to acute kidney injury.  Medications such as allopurinol or rasburicase and aggressive IV
hydration are used to prevent this complication.
(Option 2)  Anemia is also common with chemotherapy.  Epoetin (Procrit), a form of
erythropoietin, stimulates the body to make additional red blood cells.
(Option 4)  Low platelet count is not considered an urgent need until it is at <50,000/mm 3. 
Usually, platelet transfusions are given.
Educational objective:
Bone marrow suppression from chemotherapy can cause decreased red blood cells, white blood
cells, and platelets.  Erythropoietin is used to increase red blood cell production, and filgrastim is
administered to stimulate neutrophil production.
Risks of herbal medications

Herbal
Uses Adverse effects
supplement

Ginkgo biloba  Memory enhancement  Increased bleeding risk

 Improved mental
Ginseng  Increased bleeding risk
performance

 Benign prostatic
Saw palmetto  Mild stomach discomfort
hyperplasia

 Menopausal symptoms (hot

Black cohosh  Hepatic injury
flashes & vaginal dryness)

 Drug interactions:
Antidepressants (serotonin
 Depression syndrome), OCs,
St. John's wort anticoagulants (↓ INR),
 Insomnia
digoxin
 Hypertensive crisis

 Anxiety
Kava  Severe liver damage
 Insomnia

 Stomach ulcers  Hypertension

Licorice
 Bronchitis/viral infections  Hypokalemia
  Treatment & prevention of  Allergic reactions
Echinacea
cold & flu  Dyspepsia

 Hypertension
 Treatment of cold & flu  Arrhythmia/MI/sudden
Ephedra death
 Weight loss & improved
athletic performance  Stroke
 Seizure

MI = myocardial infarction; OCs = oral contraceptives.

Clients are often aware of the need to discontinue prescription medications such as aspirin and
anticoagulants prior to elective surgery, but they may not know that some herbal supplements
can increase bleeding risk.  The nurse should question the client specifically about the use of
herbal supplements.
Herbal supplements that can increase risk for bleeding include:
 Gingko biloba
 Garlic
 Ginseng
 Ginger
 Feverfew
(Option 1)  Black cohosh is used for treatment of menopausal symptoms.  The main side effect
is liver injury.
(Option 5)  Hawthorn extract is used to control hypertension and mild to moderate heart failure. 
Hawthorn use does not increase the risk of bleeding.
Educational objective:
Use of herbal supplements such as ginkgo biloba, garlic, ginseng, ginger, and feverfew should be
reported to the health care provider before surgery as they may increase the risk of bleeding.
Warfarin (Coumadin) is an anticoagulant given to clients with a mechanical valve
replacement.  To determine if the client is receiving an appropriate dose, the INR needs to be
checked regularly.  A therapeutic INR for a client with a mechanical heart valve is 2.5-3.5.  The
nurse should not administer warfarin without checking the INR first.  If the INR is >3.5, the
nurse should hold the dose and contact the health care provider for further direction.
(Option 1)  Although the nurse should assess the client's potassium level prior to administering
supplemental potassium, this medication was scheduled at 0900 and is not indicated at this time. 
There is no pharmacologic interaction between potassium levels and warfarin.
(Option 3)  The client's vital signs should be measured routinely, but administration of warfarin
and simvastatin are not contingent on the results.
(Option 4)  Verification of the client's name and date of birth is an important safety measure that
should be performed at the bedside, immediately before medication administration.
Educational objective:
The nurse should check the client's most recent INR level prior to administering warfarin.  A
therapeutic INR is 2.5-3.5 for clients with mechanical heart valves.  The nurse should hold the
dose and contact the health care provider if the INR is >3.5.

Clopidogrel (Plavix) is a platelet aggregation inhibitor used to prevent blood clot formation in

clients with recent myocardial infarction, acute coronary syndrome, cardiac stents, stroke, or
peripheral vascular disease.  Because it can cause thrombocytopenia and increase the risk for
bleeding, the nurse should notify the health care provider (HCP) of the low platelet
count (normal: 150,000-400,000/mm3 [150-400 × 109/L]) before administering clopidogrel.
(Option 1)  Calcium acetate (PhosLo) is used to control hyperphosphatemia in clients with end-
stage kidney disease by binding to phosphate in the intestines and excreting it in the stool. 
Because the phosphate level is high (normal adult: 2.4-4.4 mg/dL [0.78-1.42 mmol/L]), it is not
necessary to notify the HCP.
(Option 3)  Magnesium sulfate is used to correct hypomagnesemia and treat torsades de pointes
and seizures associated with eclampsia.  Because the magnesium level is low (normal adult: 1.5-
2.5 mEq/L [0.75-1.25 mmol/L]), it is not necessary to notify the HCP.
(Option 4)  Metformin (Glucophage) is a first-line drug for the control of blood sugar in clients
with type 2 diabetes mellitus.  Glycosylated hemoglobin (A1C) measures the total hemoglobin
that has glucose attached to it, expressed as a percentage.  Glucose remains attached to the red
blood cell for the life of the cell (about 120 days) and reflects glycemic control over an extended
period.  The recommended A1C level for a client with diabetes is <7%.  Although the A1C level is
elevated, the medication would be administered regardless of the result (unless the client is
hypoglycemic), so it is not necessary to notify the HCP.
Educational objective:
Clopidogrel (Plavix) can cause thrombocytopenia (platelet count <150,000/mm3 [150 × 109/L])
and increase a client's risk for bleeding.
Enoxaparin (Lovenox) is a low molecular weight heparin (LMWH) that may be prescribed for up
to 10-14 days following hip and knee surgery to prevent deep venous thrombosis.  Discharge
teaching for the client on enoxaparin therapy includes:
 1. Pinch an inch of skin upwards and insert the needle at a 90-degree angle into the fold of
skin.
2. Continue to hold the skin fold throughout the injection and then remove the needle at a
90-degree angle.
3. Mild pain, bruising, irritation, or redness of the skin at the injection site is common. 
Do NOT rub the site with the hand.  Using an ice cube on the injection site can provide
relief (Option 2).
4. Avoid taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal
supplements (Ginkgo biloba, vitamin E) without health care provider approval as these
can increase the risk of bleeding (Option 3).
5. Monitor complete blood count to assess for thrombocytopenia.
(Option 1)  Vitamin K-rich foods do not need to be eliminated from the diet during enoxaparin
therapy; prothrombin time (PT) and international normalized ratio (INR) are not affected. 
However, PT and INR are decreased when a vitamin K antagonist (eg, warfarin [Coumadin]) is
taken with vitamin K-rich foods.
(Option 4)  Routine coagulation studies (eg, PT, INR, partial thromboplastin time [PTT]) do not
need to be monitored in a client who is taking enoxaparin.  However, periodic assessment of
complete blood count (CBC) is usually required to monitor for hidden bleeding and
thrombocytopenia (especially in older clients with renal insufficiency).
Educational objective:
LMWH (Enoxaparin) requires monitoring of CBC (thrombocytopenia) but not coagulation
studies.  Administration of unfractionated heparin requires monitoring with PTT, whereas
warfarin requires PT/INR monitoring.  Clients on these medications should avoid aspirin and
NSAIDs.