A nurse is caring for a client who is taking clozapine. Which of the following findings should the nurse report to the provider?
Tinnitus
Dizziness
Sore throat
Diaphoresis
The Correct Answer is C
Rationale:
A. Tinnitus: Tinnitus is not a known or common adverse effect of clozapine. While it may indicate another condition, it does not require immediate reporting in the context of clozapine therapy.
B. Dizziness: Dizziness can occur due to clozapine’s hypotensive effects, especially when initiating therapy. It is usually self-limiting and managed symptomatically unless it worsens or affects safety.
C. Sore throat: A sore throat can signal the onset of agranulocytosis, a life-threatening side effect of clozapine marked by a dangerously low white blood cell count. It must be reported immediately for prompt blood count evaluation.
D. Diaphoresis: Diaphoresis may occur with many medications and is not specific to clozapine toxicity or serious adverse effects. It typically does not warrant immediate reporting unless severe or part of a broader concerning symptom complex.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Ritualistic behavior: Ritualistic or compulsive behaviors are most commonly associated with obsessive-compulsive personality disorder or obsessive-compulsive disorder, not narcissistic personality disorder.
B. Suspicious of others: Suspiciousness and distrust are hallmark features of paranoid personality disorder. While individuals with narcissistic traits may be sensitive to criticism, they are not generally suspicious in a paranoid sense.
C. Exhibits separation anxiety: Separation anxiety and fear of being alone are typically seen in dependent personality disorder and sometimes borderline personality disorder, not narcissistic personality disorder.
D. Preoccupied with aging: Clients with narcissistic personality disorder are often highly concerned with maintaining a youthful and admired image. They may fear aging due to its association with loss of beauty, status, or power, making this the expected finding.
Correct Answer is B
Explanation
Rationale:
A. Attach a single-line administration set: A blood transfusion requires a Y-type tubing with a filter and two lines—one for the blood and one for normal saline—to allow flushing and compatibility. A single-line set is inadequate.
B. Prime the tubing with 0.9% sodium chloride: Only 0.9% sodium chloride (normal saline) should be used to prime blood tubing, as it is compatible with blood products and prevents clotting or hemolysis. Dextrose or other solutions can cause cell lysis.
C. Use an IV catheter that is at least 24-gauge: A 24-gauge catheter is too small for routine blood transfusions. A larger bore, such as 18- to 20-gauge, is recommended to reduce the risk of hemolysis and allow adequate flow.
D. Use tubing that does not have a filter in the drip chamber: Blood transfusion sets must include a filter (usually 170–260 microns) to trap clots and debris. Using tubing without a filter increases the risk of transfusion reactions.
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