a nurse is providing discharge teaching for a client who has schizophrenia and is starting therapy with clozapine which of the following statements by
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Nursing Elites

ATI RN

ATI RN Exit Exam

1. A client with schizophrenia is beginning therapy with clozapine. Which statement indicates a need for further teaching?

Correct answer: D

Rationale: The correct answer is D because clients should continue taking clozapine even if their symptoms improve. Abruptly discontinuing the medication can lead to relapse. Choices A, B, and C are all correct statements regarding clozapine therapy. Regular blood work monitoring is necessary due to potential side effects, weight gain is a common side effect of clozapine, and reporting signs of fever is important as it can indicate a serious side effect of clozapine.

2. A nurse is assessing a client who is receiving morphine via a patient-controlled analgesia (PCA) pump. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: The correct answer is D because a blood pressure drop or other signs of morphine overdose should be reported, especially when using a PCA pump. Choices A, B, and C are within normal limits and do not indicate an immediate concern related to morphine administration.

3. A client is receiving warfarin for atrial fibrillation. Which of the following laboratory tests should the nurse expect to be ordered to monitor the effect of warfarin?

Correct answer: B

Rationale: The correct answer is B: International normalized ratio (INR). When a client is on warfarin therapy, the INR is monitored regularly to assess the anticoagulant effects of the medication. A therapeutic INR range for most indications is between 2.0 to 3.0. Choices A, C, and D are not typically used to monitor the effect of warfarin. Platelet count assesses the number of platelets in the blood, PT measures the clotting time of plasma, and PTT evaluates the intrinsic pathway of coagulation.

4. How should pain be assessed in a non-verbal patient?

Correct answer: A

Rationale: Observing facial expressions is essential in assessing pain levels in non-verbal patients. Non-verbal cues, such as facial grimacing, furrowed brows, or clenched jaws, can provide valuable information about the patient's pain experience. Using the Wong-Baker faces scale or assessing heart rate may not be as effective in non-verbal patients as they are unable to communicate their pain through these methods. Asking the patient to rate their pain is also not suitable for non-verbal patients as they may not have the ability to verbally communicate their pain levels.

5. What is the initial action a healthcare provider should take for a patient with chest pain?

Correct answer: A

Rationale: The correct initial action for a patient with chest pain is to administer oxygen. Chest pain can be caused by insufficient oxygenation, and providing oxygen helps alleviate the pain by increasing oxygen levels in the blood. Administering nitroglycerin or morphine may be appropriate based on the underlying cause of the chest pain, but oxygen should be given first to ensure the patient's oxygen supply is adequate. Surgery is not typically the initial intervention for chest pain.

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