Nursing Elites

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

• A. I will need to have my blood work checked regularly while taking clozapine.
• B. I understand that clozapine may cause me to gain weight.
• C. I should report any signs of a fever while taking clozapine.
• D. I should discontinue clozapine once my symptoms improve.

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. Which lab value is most critical to monitor in a patient receiving insulin therapy?

• A. Monitor blood glucose
• B. Monitor potassium levels
• C. Monitor calcium levels
• D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor blood glucose levels. When a patient is receiving insulin therapy, it is crucial to monitor blood glucose levels regularly to prevent hypoglycemia, a potential side effect of insulin therapy. Monitoring potassium, calcium, or sodium levels is important for different medical conditions or treatments and is not directly related to insulin therapy.

3. A nurse is assessing a client who is 4 hours postoperative following a total hip arthroplasty. Which of the following findings should the nurse report to the provider?

• A. Blood pressure of 118/76 mm Hg
• B. Heart rate of 88/min
• C. Urinary output of 30 mL/hr
• D. Hematocrit 42%

Correct answer: B

Rationale: The correct answer is B: 'Heart rate of 88/min.' A heart rate of 88/min in a postoperative client can be an early sign of bleeding or other complications. It is essential to report this finding promptly to the healthcare provider for further evaluation and intervention. Choices A, C, and D are within normal ranges for a postoperative client and do not indicate immediate concern. A blood pressure of 118/76 mm Hg is normal, urinary output of 30 mL/hr may be adequate depending on the client's fluid status, and a hematocrit of 42% is within the acceptable range for a postoperative client. Therefore, they do not require immediate reporting.

4. A healthcare professional is reviewing a client's laboratory results. Which of the following values is a contraindication to the administration of heparin?

• A. Hemoglobin 13 g/dL
• B. Platelet count 50,000/mm³
• C. White blood cell count 6,000/mm³
• D. INR 2.5

Correct answer: B

Rationale: The correct answer is B: Platelet count 50,000/mm³. A platelet count of 50,000/mm³ increases the risk of bleeding, making heparin contraindicated. Platelets are essential for blood clotting, and a low count can lead to excessive bleeding. Choices A, C, and D are not contraindications to heparin administration. Hemoglobin level of 13 g/dL is within the normal range, white blood cell count of 6,000/mm³ is also normal, and an INR of 2.5 is within the therapeutic range for patients receiving heparin therapy.

5. What is the initial intervention for a patient with chest pain?

• A. Administer aspirin
• B. Administer nitroglycerin
• C. Provide pain relief
• D. Prepare for surgery

Correct answer: A

Rationale: The correct initial intervention for a patient with chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation by inhibiting platelet aggregation, which can be beneficial in case the chest pain is due to a cardiac event. Administering nitroglycerin may follow aspirin administration to help relieve chest pain by dilating blood vessels. Providing pain relief is a general approach and may not address the underlying cause of chest pain. Preparing for surgery would not be the initial intervention for chest pain unless there are specific indications for immediate surgical intervention.

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