Nokea
A client with schizophrenia has been taking Clozaril (clozapine) for the past 6 months. This morning the client's temperature was elevated to 102°F. The nurse should give priority to:
- A. Placing a note in the chart for the doctor
- B. Rechecking the temperature in 4 hours
- C. Notifying the physician immediately
- D. Asking the client if he has been feeling sick
Correct Answer: C
Rationale: A fever of 102°F in a client on clozapine may indicate agranulocytosis, a life-threatening side effect, requiring immediate physician notification.
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To decrease the likelihood of seizures and visual hallucinations in a client with alcohol withdrawal, the nurse should:
- A. Keep the room darkened by pulling the curtains
- B. Keep the light over the bed on at all times
- C. Keep the room quiet and dim the lights
- D. Keep the television or radio turned on
Correct Answer: C
Rationale: A quiet, dimly lit room reduces sensory stimulation, decreasing the risk of seizures and hallucinations during alcohol withdrawal.
A client with Lyme's disease is being treated with Achromycin (tetracycline HCl). The nurse should tell the client that the medication will be rendered ineffective if taken with:
- A. Antacids
- B. Salicylates
- C. Antihistamines
- D. Sedative-hypnotics
Correct Answer: A
Rationale: Antacids containing calcium, magnesium, or aluminum can bind tetracycline, reducing its absorption and effectiveness.
A community center is having a health fair. Which of the following main food courses should the nurse recommend as most healthful for a 20-year-old adult whose total cholesterol level is 300 mg/dL?
- A. fettuccine alfredo
- B. fried chicken
- C. grilled cheese sandwich with bacon
- D. natural peanut butter and banana sandwich on whole wheat bread
Correct Answer: D
Rationale: The peanut butter and banana sandwich on whole wheat bread is lower in saturated fats and healthier for managing high cholesterol.
The physician prescribes captopril (Capoten) 25 mg po tid for the client with hypertension. Which of the following adverse reactions can occur with administration of Capoten?
- A. Tinnitus
- B. Persistent cough
- C. Muscle weakness
- D. Diarrhea
Correct Answer: B
Rationale: Captopril, an ACE inhibitor, commonly causes a persistent dry cough.
The nurse is caring for a client receiving hemodialysis. During hemodialysis, the client becomes anxious, experiencing tachypnea and hypotension. The nurse suspects which complication of hemodialysis?
- A. air embolism
- B. clotting of the graft site
- C. dialysis encephalopathy
- D. disequilibrium syndrome
Correct Answer: D
Rationale: Disequilibrium syndrome can occur during hemodialysis due to rapid shifts in fluids and electrolytes, causing symptoms like anxiety, tachypnea, and hypotension.