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 C
Explanation
Rationale:
A. Maintain bed elevation at 20°: To reduce the risk of aspiration, the head of the bed should be elevated to at least 30°–45° during and after enteral feedings. A 20° elevation is insufficient to prevent gastric reflux and aspiration.
B. Check for gastric residual every 12 hr: Gastric residuals should generally be checked every 4–6 hours for clients receiving continuous enteral feedings. Waiting 12 hours increases the risk of feeding intolerance or aspiration from undetected residual accumulation.
C. Flush the tubing with 30 mL of water every 4 hr: Routine flushing helps prevent tube occlusion and maintains patency. It also ensures that the client receives adequate hydration, especially with continuous feeding systems.
D. Place enough formula in the container to last 18 hr: Formula in an open system should not hang longer than 4 hours due to the risk of bacterial contamination. Adding 18 hours’ worth increases the chance of microbial growth and infection.
Correct Answer is D
Explanation
Rationale:
A. Protamine: Protamine is used to reverse the effects of heparin, particularly in cases of heparin overdose or to stop excessive bleeding. It does not treat allergic reactions like urticaria.
B. Naloxone: Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression or overdose. It has no effect on histamine-mediated symptoms such as urticaria.
C. Hydralazine: Hydralazine is an antihypertensive medication that lowers blood pressure by relaxing arterial smooth muscle. It is not appropriate for managing allergic skin reactions.
D. Diphenhydramine: Diphenhydramine is an antihistamine that blocks histamine receptors, making it effective for treating allergic reactions such as urticaria (hives). It reduces itching, swelling, and redness caused by histamine release.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.