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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Rationale:

A. Monitor the client for hypertension: Epidural anesthesia commonly causes hypotension due to sympathetic nervous system blockade, not hypertension. Monitoring for hypotension is more appropriate.

B. Have protamine sulfate available at the bedside: Protamine sulfate is the antidote for heparin, not epidural anesthesia. It has no relevance in managing epidural-related effects during labor.

C. Reposition the client side-to-side each hour: Changing positions frequently helps promote venous return, enhance placental perfusion, and reduce the risk of pressure injuries and aortocaval compression from a supine position.

D. Decrease the maintenance infusion rate of IV fluid: IV fluids are typically increased before and during epidural anesthesia to prevent or manage hypotension, not decreased. Reducing the rate could worsen hypotension.

A. veracity B. Fidelity C. Beneficence D. Autonomy

Correct Answer is C

Explanation

Rationale:

A. Veracity: Veracity involves telling the truth and providing accurate information. While important in building trust, it is not the ethical principle most relevant to offering emotional presence during grief.

B. Fidelity: Fidelity refers to being faithful to promises and responsibilities, including maintaining confidentiality and following through on care. It does not specifically reflect the act of offering comfort in grief.

C. Beneficence: Beneficence is the act of doing good and promoting the well-being of others. By sitting with the grieving client to provide comfort, the nurse is demonstrating compassion and aiming to alleviate suffering.

D. Autonomy: Autonomy refers to respecting a client’s right to make their own decisions regarding care. While essential in healthcare, it does not directly relate to the nurse’s compassionate presence during bereavement.

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A nurse is caring for a client who is taking clozapine. Which of the following findings should the nurse report to the provider?

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