Nokea
A client with a diagnosis of schizophrenia is prescribed clozapine (Clozaril). The nurse should monitor the client for which of the following serious side effects?
- A. Weight gain.
- B. Agranulocytosis.
- C. Dry mouth.
- D. Insomnia.
Correct Answer: B
Rationale: Clozapine can cause agranulocytosis, a life-threatening reduction in white blood cells, requiring regular monitoring of white cell counts.
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A child with a diagnosis of sickle cell disease is admitted to the hospital for treatment of vaso-occlusive pain crisis. The nurse should plan for which interventions in the care of the client? Select all that apply.
- A. Increase fluid intake.
- B. Administer oxygen.
- C. Administer meperidine.
- D. Perform frequent pain assessment.
- E. Administer intravenous (IV) fluids.
Correct Answer: A,B,D,E
Rationale: Management of the severe pain that occurs with vaso-occlusive crisis includes frequent pain assessment and the use of strong opioid analgesics, such as morphine sulfate and hydromorphone. Fluids are necessary to promote hydration, so options related to the delivery of fluids are appropriate. Oxygen is administered to increase tissue perfusion. Meperidine is contraindicated because of its side effects and increased risk of seizures after as few as 2 doses.
As the registered nurse in the emergency department, you are taking care of an adolescent client who had just fractured their femur during gymnasium class at their high school. After casting, you will be discharging the client with crutches. Which of the following client goals that is paired with its learning domain should be included in the patient teaching plan for this client and the parents?
- A. Psychomotor domain: The client will slightly bend their elbows when holding the hand grips.
- B. Psychomotor domain: The client will rest their weight on the padded areas on the top of the crutches.
- C. Cognitive domain: The client will slightly bend their elbows when holding the hand grips.
- D. Cognitive domain: The nurse will tell the client how often the tips on the crutches must be replaced.
Correct Answer: A
Rationale: Proper crutch use involves psychomotor skills, such as slightly bending the elbows when holding the hand grips, to ensure safe and effective mobility.
The nurse is caring for a client who has just undergone a nephrectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Monitor urine output.
- B. Encourage early ambulation.
- C. Administer oral fluids immediately.
- D. Keep the client on bed rest for 48 hours.
Correct Answer: A
Rationale: Monitoring urine output is critical post-nephrectomy to assess the function of the remaining kidney.
The nurse is monitoring a client who has received antidysrhythmic therapy for the treatment of premature ventricular contractions (PVCs). Which observation in the PVCs would indicate to the nurse that this therapy is ineffective?
- A. Occur in pairs
- B. Be unifocal in appearance
- C. Be fewer than 6 per minute
- D. Fall after the end of the T wave
Correct Answer: A
Rationale: PVCs are considered dangerous when they are frequent (more than 6 per minute), occur in pairs or couplets, are multifocal (multiform), or fall on the T wave.
The nurse is caring for a client with a history of breast cancer who is receiving radiation therapy. Which of the following instructions should the nurse include in the client's teaching?
- A. Apply lotion to the radiated area immediately after treatment.
- B. Avoid exposing the radiated area to sunlight.
- C. Wash the radiated area with soap and water daily.
- D. Wear tight clothing over the radiated area.
Correct Answer: B
Rationale: Avoiding sunlight exposure protects the radiated skin from further damage and reduces irritation.