Nursing Elites

1. A client with schizophrenia taking clozapine is being assessed by a nurse. Which of the following findings is the priority for the nurse to report to the provider?

• A. Elevated blood pressure
• B. Fever
• C. Weight gain
• D. Dry mouth

Correct answer: B

Rationale: The priority finding for the nurse to report to the provider is B: Fever. Fever can be an indication of agranulocytosis, a potentially life-threatening condition associated with clozapine. Agranulocytosis is characterized by a significant decrease in white blood cells, making the client susceptible to severe infections. Prompt reporting of fever is crucial to prevent serious complications. Elevated blood pressure (Choice A), weight gain (Choice C), and dry mouth (Choice D) are important to monitor but are not as immediately concerning as fever, which could indicate a severe adverse reaction requiring urgent medical attention.

2. A client is wearing a continuous cardiac monitor, which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. What should the nurse do first?

• A. Call a code blue.
• B. Call the healthcare provider.
• C. Check the client's status and lead placement.
• D. Press the recorder button on the ECG console.

Correct answer: C

Rationale: The correct first action for the nurse to take is to check the client's status and lead placement. This step is crucial to ensure that the alarm is not triggered by a simple issue such as lead displacement. Calling a code blue (choice A) is premature without assessing the client first. Contacting the healthcare provider (choice B) can be done after ruling out basic causes for the alarm. Pressing the recorder button (choice D) is not as urgent as checking the client's status and lead placement in this scenario.

3. A client with a history of coronary artery disease is prescribed atorvastatin (Lipitor). What side effect should the nurse instruct the client to immediately report?

• A. Muscle pain or tenderness
• B. Constipation
• C. Dry mouth
• D. Drowsiness

Correct answer: A

Rationale: The correct answer is 'Muscle pain or tenderness.' This can be a sign of rhabdomyolysis, a serious side effect of statins like atorvastatin (Lipitor). Rhabdomyolysis is a condition in which muscle breakdown releases a protein that can damage the kidneys. Therefore, it is crucial for the client to report any muscle pain or tenderness immediately to prevent further complications. Choices B, C, and D are incorrect because they are not typically associated with atorvastatin (Lipitor) use or indicative of a serious adverse effect that requires immediate reporting.

4. A client has a new prescription for verapamil. Which of the following instructions should the nurse include?

• A. Monitor your heart rate daily.
• B. Take the medication at bedtime.
• C. Avoid consuming grapefruit juice.
• D. Take the medication with food.

Correct answer: A

Rationale: The correct answer is to instruct the client to monitor their heart rate daily when taking verapamil. Verapamil is a calcium channel blocker that can cause bradycardia, making it crucial to monitor the heart rate regularly to detect any changes promptly. Choice B, taking the medication at bedtime, is not specifically related to verapamil administration. Choice C, avoiding grapefruit juice, is more relevant to medications metabolized by CYP3A4 enzymes, not verapamil. Choice D, taking the medication with food, is not a specific instruction for verapamil, as it can be taken with or without food.

5. A client is diagnosed with thrombophlebitis. The nurse should tell the client that which prescription is indicated?

• A. Bed rest, with bathroom privileges only
• B. Bed rest, keeping the affected extremity flat
• C. Bed rest, with elevation of the affected extremity
• D. Bed rest, with the affected extremity in a dependent position

Correct answer: C

Rationale: The correct answer is C: Bed rest, with elevation of the affected extremity. Elevating the affected extremity is crucial in managing thrombophlebitis as it helps reduce swelling and promotes venous return. By elevating the affected extremity, the gravitational force assists in venous blood flow back to the heart, thereby reducing the risk of complications associated with thrombophlebitis. Choices A, B, and D are incorrect because they do not address the need for elevation, which is specifically beneficial in the management of thrombophlebitis.

Similar Questions