A client with a history of schizophrenia is prescribed olanzapine (Zyprexa). The nurse should monitor the client for which of the following adverse effects?
- A. Weight gain.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: A
Rationale: Olanzapine commonly causes weight gain, requiring monitoring.
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The nurse coordinates with the laboratory staff to have the gentamicin trough serum level drawn. At what time should the blood be drawn in relation to the administration of the I.V. dose of gentamicin sulfate [Garamycin]?
- A. 2 hours before the administration of the next I.V. dose.
- B. 3 hours before the administration of the next I.V. dose.
- C. 4 hours before the administration of the next I.V. dose.
- D. Just before the administration of the next I.V. dose.
Correct Answer: D
Rationale: The trough level, which measures the lowest drug concentration, is drawn just before the next dose to ensure the drug is within a therapeutic range and to avoid toxicity.
The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the chart below. The nurse compares these findings to the Apgar score obtained at birth, as determined by the findings in the chart below. What should the nurse do next?
- A. Notify the neonatologist on call.
- B. Continue to assess the neonate.
- C. Apply an oxygen mask.
- D. Rub the neonate's extremities.
Correct Answer: B
Rationale: Without specific Apgar score data, the standard action is to continue assessing the neonate, as Apgar scores at 5 minutes guide ongoing monitoring unless critical findings are present.
When you are monitoring your client who is now started on an intravenous antibiotic for an infection, you notice that the client is exhibiting signs of anaphylaxis. What is your first priority intervention?
- A. Stop the intravenous flow
- B. Slow down the intravenous flow
- C. Notify the doctor
- D. Begin CPR
Correct Answer: A
Rationale: Stopping the IV flow is the first priority to halt the administration of the allergen causing anaphylaxis, followed by other emergency interventions.
A client has just been admitted with acute delirium of unknown etiology. The client's daughter states that she is worried about her mom because she has never acted this way before. The nurse's best response is:
- A. I understand your concern. Let's discuss what specific changes you've noticed.'
- B. Delirium is common in older adults and usually resolves quickly.'
- C. We'll run some tests to find out what's causing this behavior.'
- D. Don't worry, we'll take good care of her.'
Correct Answer: A
Rationale: Discussing specific changes encourages the daughter to provide details, aiding in identifying the delirium's cause and tailoring care.
The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse determines that the UAP understands the type of information to report to the nurse when the UAP reports which of the following about one of the clients?
- A. An episode of nausea after administration of an epidural anesthetic.
- B. Contractions 3 minutes apart and lasting 40 seconds.
- C. Scream of spontaneous rupture of the membranes.
- D. Sleeping after administration of I.V. nalbuphine (Nubain).
Correct Answer: A,C
Rationale: Nausea after an epidural and spontaneous rupture of membranes are significant events requiring nurse assessment due to potential complications. Contractions and sleeping are expected findings.
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