A nurse is assessing a client who is taking clozapine. For which of the following adverse effects should the nurse monitor and report to the provider?
Sore throat
Tinnitus
Rhinitis
Headache
The Correct Answer is A
Rationale:
A. Sore throat: A sore throat may indicate agranulocytosis, a serious adverse effect of clozapine that results in dangerously low white blood cell counts. Early signs include fever, sore throat, and malaise. This requires immediate reporting and evaluation with a complete blood count.
B. Tinnitus: Tinnitus is not a known or common adverse effect of clozapine. While bothersome, it is not typically associated with the hematologic or metabolic risks posed by this antipsychotic medication.
C. Rhinitis: Although rhinitis can occur with many medications, it is not a serious or expected side effect of clozapine requiring urgent attention. Mild nasal symptoms are usually self-limiting and not indicative of life-threatening complications.
D. Headache: Headaches are common and nonspecific symptoms that may result from various causes. Unless severe or persistent, they do not typically indicate a dangerous reaction to clozapine and are not prioritized over signs of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Alkaline phosphatase: This enzyme is typically used to assess liver or bone disorders, not renal function. Although some values may rise due to medications or illness, it is not a primary marker for kidney health in transplant clients.
B. Amylase: Amylase is used to evaluate pancreatic function and is not directly related to kidney function. It may be elevated in pancreatitis or abdominal conditions, but it does not provide information about renal performance.
C. Creatinine: Serum creatinine is a key indicator of renal function and is commonly monitored alongside BUN in clients taking nephrotoxic drugs like cyclosporine. Elevations may signal impaired kidney function or transplant rejection.
D. Bilirubin: Bilirubin reflects liver function and bile metabolism rather than kidney function. Although important in overall health assessment, it is not used to evaluate renal function in clients post-transplant.
Correct Answer is C
Explanation
Rationale:
A. Administer magnesium sulfate to the client: Magnesium sulfate is typically used for neuroprotection before 32 weeks or to manage preeclampsia; it is not indicated for rupture of membranes at 36 weeks unless there are other risk factors.
B. Administer betamethasone to the client: Betamethasone is used to enhance fetal lung maturity, most beneficial before 34 weeks. At 36 weeks, the lungs are usually mature enough that corticosteroids are not routinely indicated.
C. Monitor the client's temperature every 2 hr: This helps detect early signs of chorioamnionitis, a serious infection risk after membrane rupture, especially with prolonged rupture.
D. Monitor fetal heart rate every 4 hr: Fetal heart monitoring should be more frequent in the presence of membrane rupture to promptly identify signs of distress or infection, not every 4 hours.
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