Nursing Elites

1. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine?

• A. WBC count 2,900 /mm3.
• B. Fasting blood glucose 100 mg/dl.
• C. Hgb 14 g/dl.
• D. Heart rate 58/min.

Correct answer: A

Rationale: A WBC count of 2,900/mm3 indicates leukopenia, which is a serious side effect of clozapine and contraindicates its use. Leukopenia is a significant concern with clozapine therapy due to the risk of agranulocytosis, a potentially life-threatening condition. Monitoring the WBC count is crucial to detect this adverse effect early. The other options (B, C, and D) are within normal ranges and not contraindications for administering clozapine.

2. What should a person recommend to a client experiencing constipation?

• A. Increase fluid intake to prevent further dehydration
• B. Increase dietary fiber to promote regular bowel movements
• C. Administer a laxative to relieve constipation
• D. Encourage bed rest to allow for bowel function to return

Correct answer: B

Rationale: Increasing dietary fiber is an effective recommendation for clients experiencing constipation as it helps promote regular bowel movements. Choice A, increasing fluid intake, is also important but the most appropriate initial recommendation for constipation is to increase dietary fiber. Choice C, administering a laxative, should not be the first-line recommendation and is typically considered after dietary and lifestyle interventions. Choice D, encouraging bed rest, does not directly address constipation relief or prevention.

3. A client post-lumbar puncture should be in which position?

• A. High Fowler's position
• B. Prone position
• C. Supine position
• D. Sitting position

Correct answer: C

Rationale: The most appropriate position for a client post-lumbar puncture is the supine position. Placing the client in a supine position helps prevent spinal headaches by allowing the puncture site to seal effectively and reducing the risk of cerebrospinal fluid leakage. High Fowler's position, prone position, and sitting position are not recommended after a lumbar puncture as they may increase the risk of complications like spinal headaches.

4. What is the most appropriate safety measure for a client using home oxygen?

• A. Store oxygen tanks upright when not in use
• B. Ensure oxygen tanks are kept upright at all times
• C. Allow family members to smoke in designated areas
• D. Keep oxygen equipment at least 10 feet away from heat sources

Correct answer: B

Rationale: The correct answer is to ensure oxygen tanks are kept upright at all times. This is important to prevent the tanks from falling over, which can lead to injuries or tank damage. Choice A is incorrect because oxygen tanks should not be stored in a closet when not in use, as this can lead to poor ventilation and potential hazards. Choice C is incorrect because smoking near oxygen tanks poses a significant fire risk. Choice D is incorrect because while it is important to keep oxygen equipment away from heat sources, ensuring the tanks are kept upright is a more critical safety measure.

5. What should a healthcare professional prioritize when managing a client with delirium?

• A. Administering sedative medication
• B. Providing a low-stimulation environment
• C. Identifying the underlying cause of the delirium
• D. Controlling behavioral symptoms with medication

Correct answer: C

Rationale: When managing a client with delirium, the priority should be to identify the underlying cause of the delirium. Delirium can result from various triggers such as infections, medication side effects, or metabolic imbalances. By determining the root cause, healthcare professionals can provide targeted treatment and improve outcomes. Administering sedative medication (Choice A) could exacerbate delirium as these drugs can worsen confusion. While providing a low-stimulation environment (Choice B) is beneficial, it is not as critical as identifying the cause. Controlling behavioral symptoms with medication (Choice D) should only be considered after identifying and addressing the underlying cause of delirium.

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