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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A) Incorrect. The client should not avoid eating foods that are high in vitamin K, such as leafy greens, broccoli, and soybeans. These foods can interfere with the anticoagulant effect of warfarin and increase the risk of clotting. The client should eat a consistent amount of vitamin K-rich foods and avoid sudden changes in their intake.

B) Correct. The client should use a soft-bristled toothbrush to prevent bleeding from the gums. Warfarin can impair the blood's ability to clot and increase the risk of bleeding from minor injuries.

C) Correct. The client should monitor their blood pressure regularly at home and report any abnormal readings to their provider. Warfarin can affect blood pressure and increase the risk of stroke or bleeding.

D) Correct. The client should report any signs of bruising or bleeding to their provider, such as nosebleeds, blood in urine or stool, heavy menstrual bleeding, or prolonged bleeding from cuts. These signs may indicate that the warfarin dose is too high and needs adjustment.

A. The nurse injects air into the NPH vial first, then into the regular vial. B. The nurse draws up regular insulin first, then NPH insulin. C. The nurse rolls the NPH vial between their palms before drawing up insulin. D. The nurse wipes the rubber stoppers of both vials with alcohol swabs.

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has been prescribed warfarin for atrial fibrillation. Which of the following statements by the client indicates a need for further education?

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Explanation

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Correct Answer is B

Explanation

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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?

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