a male client is prescribed clozapine clozaril an antipsychotic medication for the management of schizophrenia which client history should the nurse r
Logo

Nursing Elites

HESI RN

HESI 799 RN Exit Exam

1. A male client is prescribed clozapine (Clozaril), an antipsychotic medication, for the management of schizophrenia. Which client history should the nurse report to the healthcare provider before administering the first dose of this medication?

Correct answer: B

Rationale: The correct answer is B: History of cardiac arrhythmia. Clozapine can lead to severe cardiovascular problems, making it crucial to report any history of cardiac arrhythmia to the healthcare provider before administering the medication. Choices A, C, and D are less concerning in this context as they are not directly associated with potential serious complications related to clozapine use.

2. A client with hypertension receives a prescription for enalapril, an angiotensin-converting enzyme (ACE) inhibitor. Which instruction should the nurse include in the medication teaching plan?

Correct answer: B

Rationale: The correct instruction for the nurse to include in the medication teaching plan is to 'Report increased bruising or bleeding.' ACE inhibitors can cause thrombocytopenia, which lowers platelet count and increases the risk of bruising and bleeding. Choice A is incorrect because while ACE inhibitors may cause potassium levels to increase, the instruction should not be to increase intake of potassium-rich foods without healthcare provider guidance. Choice C is incorrect because a cough is a common side effect of ACE inhibitors due to bradykinin accumulation, and stopping the medication abruptly is not recommended without consulting the healthcare provider. Choice D is incorrect because there is no need to limit intake of leafy green vegetables specifically with ACE inhibitors; however, consistent intake of vitamin K-rich foods is recommended to maintain a stable INR for clients taking anticoagulants.

3. The nurse is assessing a client with left-sided heart failure. Which assessment finding is most concerning?

Correct answer: C

Rationale: Shortness of breath is the most concerning finding in a client with left-sided heart failure as it indicates worsening pulmonary congestion and impaired gas exchange. This symptom suggests that the client is experiencing significant difficulty in breathing and inadequate oxygenation, requiring immediate intervention. Jugular venous distention (Choice A) is often seen in right-sided heart failure, while peripheral edema (Choice B) and crackles in the lungs (Choice D) are common manifestations of left-sided heart failure but are not as acutely concerning as severe shortness of breath, which can rapidly progress to respiratory distress if not addressed promptly.

4. In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, the nurse assesses that the client is lethargic with a blood pressure of 90/60, pulse rate of 118 beats per minute, and respiratory rate of 8 breaths per minute. What assessment should the nurse perform next?

Correct answer: D

Rationale: In this scenario, the nurse is dealing with a lethargic client with concerning vital signs after a PCA infusion of morphine sulfate. The next assessment the nurse should perform is to observe the amount and dose of morphine in the PCA pump syringe. This is crucial to evaluate for possible overdose, as the client's symptoms could be indicative of opioid toxicity. Checking the morphine amount and dose will help the nurse adjust the treatment accordingly. Choices A, B, and C do not directly address the potential cause of the client's lethargy and abnormal vital signs related to the morphine infusion.

5. The nurse is triaging several children as they present to the emergency room after an accident. Which child requires the most immediate intervention by the nurse?

Correct answer: A

Rationale: The correct answer is A. Projectile vomiting in a child with a headache could indicate increased intracranial pressure, requiring immediate attention. Choices B, C, and D do not present with symptoms indicating potentially life-threatening conditions that require urgent intervention.

Similar Questions

A client with a history of hypertension is prescribed a beta-blocker. Which client statement indicates that further teaching is needed?
A male client with ulcerative colitis received a prescription for a corticosteroid last month, but because of the side effects, he stopped taking the medication 6 days ago. Which finding warrants immediate intervention by the nurse?
A male client with rheumatoid arthritis is scheduled for a procedure in the morning. The procedure cannot be completed due to early morning stiffness. Which intervention should the nurse implement?
When preparing to insert a nasogastric (NG) tube for a client admitted to the surgical unit with symptoms of a possible intestinal obstruction, which intervention should the nurse implement?
A 46-year-old male client who had a myocardial infarction 24 hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses