A nurse is caring for a client who has schizophrenia and is taking clozapine. The nurse notices that the client has a fever, sore throat, and malaise. Which of the following actions should the nurse take?
Administer acetaminophen to the client.
Obtain a blood sample from the client for a complete blood count.
Encourage the client to drink plenty of fluids and rest.
Discontinue clozapine and notify the provider.
The Correct Answer is B
B) Correct. The nurse should obtain a blood sample from the client for a complete blood count as these symptoms can indicate agranulocytosis, a potentially fatal adverse effect of clozapine that causes a severe decrease in white blood cells and increases the risk of infection.
A) Incorrect. The nurse should not administer acetaminophen to the client as this drug can mask the signs of infection and delay diagnosis and treatment of agranulocytosis.
C) Incorrect. The nurse should encourage the client to drink plenty of fluids and rest, but this action alone would not address the potential serious adverse effect of agranulocytosis associated with clozapine. Obtaining a blood sample for a complete blood count is necessary to assess the client's white blood cell count and determine if agranulocytosis is present.
D) Incorrect. Discontinuing clozapine and notifying the provider is important, but it should be done after obtaining a blood sample for a complete blood count to confirm the presence of agranulocytosis. This allows for appropriate medical management and alternative treatment options to be initiated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect. The nurse should inject air into the regular vial first, then into the NPH vial. This can prevent contamination of the regular insulin with NPH insulin and ensure accurate dosing.
B) Correct. The nurse should draw up regular insulin first, then NPH insulin. This can prevent contamination of the regular insulin with NPH insulin and ensure accurate dosing. Regular insulin is clear and NPH insulin is cloudy.
C) Correct. The nurse should roll the NPH vial between their palms before drawing up insulin. This can resuspend the insulin particles that may have settled at the bottom of the vial and ensure uniform concentration.
D) Correct. The nurse should wipe the rubber stoppers of both vials with alcohol swabs before inserting needles. This can reduce the risk of infection and contamination.
Correct Answer is A
Explanation
A) Correct. The nurse should advise the client to limit spinach in their diet as this food is high in vitamin K, which can antagonize the anticoagulant effect of warfarin and increase the risk of thrombosis.
B) Incorrect. The nurse should not advise the client to limit bananas in their diet as this food is high in potassium, which can help prevent hypokalemia that can occur with some anticoagulants such as heparin. Bananas do not affect the action of warfarin.
C) Incorrect. The nurse should not advise the client to limit cheese in their diet as this food is high in calcium, which can help prevent osteoporosis that can occur with long-term use of warfarin. Cheese does not affect the action of warfarin.
D) Incorrect. The nurse should not advise the client to limit eggs in their diet as this food is high in protein, which can help maintain muscle mass and wound healing that can be impaired by warfarin. Eggs do not affect the action of warfarin.
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