a patient with depression is prescribed fluoxetine what is an important side effect for the nurse to monitor
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1. A patient with depression is prescribed fluoxetine. What is an important side effect for the nurse to monitor?

Correct answer: D

Rationale: When a patient with depression is prescribed fluoxetine, the nurse should be vigilant for the potential side effect of increased risk of suicidal thoughts. Fluoxetine, like other antidepressants, may elevate the risk of suicidal thoughts, particularly during the initial phases of treatment. Monitoring the patient for any indications of heightened depression or suicidal ideation is crucial to ensure appropriate interventions are implemented promptly.

2. A client who participates in a health maintenance organization (HMO) needs a bone marrow transplant for the treatment of breast cancer. The client tells the nurse that she is concerned that her HMO may deny her claim. What action by the nurse best addresses the client's need at this time?

Correct answer: B

Rationale: The best action for the nurse to take in this situation is to help the client directly contact the HMO to seek information about limitations of coverage. This approach addresses the client's immediate concerns and clarifies the situation, enabling the client to understand the coverage and potential outcomes regarding the bone marrow transplant. Choice A is not the best option as having the healthcare provider write a letter may not provide immediate clarification on coverage. Choice C is inappropriate as legal action should be considered as a last resort, and choice D involving the state board of insurance is not necessary at this initial stage of addressing the client's concern.

3. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which intervention should the nurse implement to ensure the client's safety?

Correct answer: C

Rationale: Using a nasal cannula to deliver oxygen at a low flow rate is the appropriate intervention for clients with COPD receiving oxygen therapy. High flow rates can lead to respiratory depression in COPD patients. This intervention helps maintain a safe and controlled oxygen delivery to prevent potential complications associated with high oxygen flow rates.

4. A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse?

Correct answer: D

Rationale: Respirations that are shallow, labored, and at 14 breaths/minute indicate potential respiratory compromise, which is a critical situation requiring immediate intervention to maintain adequate oxygenation and prevent respiratory failure.

5. A patient with type 1 diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). What is the priority nursing action?

Correct answer: A

Rationale: The priority nursing action for a patient with type 1 diabetes mellitus admitted with diabetic ketoacidosis (DKA) is to administer regular insulin intravenously. Insulin helps to lower blood glucose levels and correct acidosis, which are critical in managing DKA. Administering oral hypoglycemic agents is not appropriate in the acute setting of DKA as they may not work quickly enough compared to intravenous insulin. While sodium bicarbonate may be used to correct acidosis, insulin administration is the priority to address both hyperglycemia and acidosis simultaneously. Providing a high-calorie diet is not suitable initially in DKA management; the main focus is on stabilizing the patient's condition through insulin therapy and fluid/electrolyte correction.

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