Nokea
A nurse is assessing a client who is receiving clozapine (Clozaril). The nurse reviews the chart below. What should the nurse do next?
- A. Give the clozapine, and tell the client to lie down.
- B. Withhold the clozapine, and tell the client to go to an exercise group.
- C. Administer the clozapine, and notify the physician.
- D. Withhold the clozapine, and notify the physician.
Correct Answer: D
Rationale: Clozapine requires monitoring for agranulocytosis; abnormal findings (e.g., low white blood cell count) warrant withholding the drug and notifying the physician to prevent serious complications.
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A 4-year-old child who has been ill for 4 hours is admitted to the hospital with difficulty swallowing, a sore throat, and severe substernal retractions. The child's temperature is 104°F (40°C), and the apical pulse is 140 bpm.The white blood cell count is 16,000/mm³. Which of the following should the nurse identify as the immediate priority nursing diagnosis?
- A. Anxiety related to need for immediate and unplanned hospitalization.
- B. Risk for injury (airway obstruction) related to epiglottal edema.
- C. Impaired gas exchange related to excessive respiratory effort.
- D. Ineffective airway clearance related to aspiration.
Correct Answer: B
Rationale: The symptoms indicate epiglottitis, with a high risk of airway obstruction due to epiglottal edema, making this the priority diagnosis.
A female client is treated for trichomoniasis with metronidazole (Flagyl). The nurse instructs the client that:
- A. The medication should not alter the color of the urine.
- B. She should discontinue oral contraceptive use during this treatment.
- C. She should avoid alcohol during treatment and for 24 hours after completion of the drug.
- D. Her partner does not need treatment.
Correct Answer: C
Rationale: Metronidazole can cause a disulfiram-like reaction with alcohol, so avoiding alcohol during and 24 hours after treatment is critical.
You will be providing nursing care prior to, during and after electroconvulsive therapy for your client who is severely depressed. Which of the following is an appropriate nursing intervention for this client?
- A. Maintain the client with NPO status for at least 4 hours prior to this procedure.
- B. Teach the client about the fact that they may experience muscle flaccidity.
- C. Teach the client about the fact that they may have a headache after the ECT.
- D. Maintain the client on continuous hemodynamic monitoring after the ECT.
Correct Answer: C
Rationale: Headache is a common side effect of ECT, and educating the client about this prepares them for post-procedure expectations.
What ethical principle below is accurately paired with a way that ethical principle is applied into nursing practice?
- A. Justice: Equally dividing time and other resources among a group of clients
- B. Beneficence: Doing no harm during the course of nursing care
- C. Veracity: Fully answering the client's questions without any withholding of information
- D. Fidelity: Upholding the American Nurses Association's Code of Ethics
Correct Answer: C
Rationale: Veracity is accurately paired with fully answering the client's questions without withholding information, as it emphasizes truthfulness in nursing practice. Justice involves fair treatment, not just equal time ; Beneficence involves promoting good, not just avoiding harm ; Fidelity is about keeping promises, not specifically the ANA Code .
The nurse is monitoring a client who is receiving a blood transfusion when the client reports diaphoresis, warmth, and a backache. The nurse should take which actions? Select all that apply.
- A. Remove the IV catheter.
- B. Document the occurrence.
- C. Stop the blood transfusion.
- D. Contact the primary health care provider.
- E. Hang 0.9% sodium chloride solution.
Correct Answer: B,C,D,E
Rationale: If a client experiences diaphoresis, warmth, and a backache, a transfusion reaction is suspected. The nurse stops the transfusion and prevents the infusion of any additional blood; then the nurse hangs a bag of 0.9% sodium chloride solution. This maintains IV access and helps maintain the client's intravascular volume. The primary health care provider is notified, as is the blood bank. The nurse also documents the occurrence, the actions taken, and the client's response. To preserve the IV access, the nurse should not remove the catheter and discontinue the IV site.