A nurse is planning to administer olanzapine 10 mg IM to a client who has schizophrenia. Which of the following actions should the nurse take?

Administer the medication into the deltoid muscle.

Monitor the client for at least 3 hr after the injection.

Withhold the medication if the client reports hallucinations.

Instruct the client to expect difficulty sleeping

Answer and Explanation

The Correct Answer is B

A. Administer the medication into the deltoid muscle: Olanzapine is typically administered deep into the muscle to ensure proper absorption. However, the deltoid muscle may not be the preferred site for intramuscular injections of medications like olanzapine due to the risk of hitting the underlying radial nerve. The ventrogluteal or vastus lateralis muscles are often preferred sites for IM injections to reduce the risk of nerve damage.
B. Monitor the client for at least 3 hr after the injection: After administering olanzapine IM, the nurse should monitor the client closely for at least 3 hours to assess for any adverse reactions or side effects, such as sedation, hypotension, or extrapyramidal symptoms. This allows for early detection and prompt intervention if needed.
C. Withhold the medication if the client reports hallucinations: Olanzapine is an antipsychotic medication commonly used to treat schizophrenia and other psychotic disorders. Hallucinations are a symptom of schizophrenia, and olanzapine is often prescribed to help manage such symptoms. Withholding the medication solely based on the client reporting hallucinations would not be appropriate without further assessment and consideration of the overall treatment plan.
D. Instruct the client to expect difficulty sleeping: While olanzapine can cause sedation and may affect sleep patterns in some individuals, it is not a universal side effect for everyone. Providing anticipatory guidance about potential side effects is essential, but instructing the client to expect difficulty sleeping without individual assessment may lead to unnecessary anxiety or concerns.

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Correct Answer is ["C","D","E"]

Explanation

A. Increase hematocrit: Fluid overload typically leads to hemodilution, resulting in a decrease in hematocrit rather than an increase. Therefore, an increase in hematocrit would not be expected in a client with fluid overload.
B. Increased temperature: Fluid overload is not typically associated with an increased body temperature. Instead, fever may indicate an infection or another underlying cause. Therefore, an increased temperature would not be a typical finding in a client with fluid overload.
C. Increased heart rate: Fluid overload can lead to an increased heart rate as the body attempts to maintain adequate cardiac output in the presence of excess fluid volume. An elevated heart rate is a compensatory mechanism to maintain tissue perfusion despite the increased workload on the heart.
D. Increased respiratory rate: Fluid overload can cause pulmonary congestion, leading to increased respiratory effort and a higher respiratory rate as the body attempts to compensate for decreased gas exchange efficiency. An increased respiratory rate helps to improve oxygenation and remove excess carbon dioxide from the body.
E. Increased blood pressure: Fluid overload often leads to increased blood pressure due to the increased volume of circulating blood, which can strain the cardiovascular system. Elevated blood pressure is a common manifestation of fluid overload and reflects the increased workload on the heart and blood vessels.

A. Pancrelipase 500 units/kg PO three times daily with meals B. Pantoprazole 80 mg IV bolus twice daily C. Initiate a low-residue diet D. D Ambulate twice day

Correct Answer is B

Explanation

A. Pancrelipase 500 units/kg PO three times daily with meals: Pancrelipase is an enzyme replacement therapy used to aid in the digestion of fats, proteins, and carbohydrates in clients with pancreatic insufficiency. However, in acute pancreatitis, the pancreas is inflamed and typically unable to produce sufficient enzymes. Therefore, enzyme replacement therapy is not typically initiated during the acute phase of pancreatitis.
B. Pantoprazole 80 mg IV bolus twice daily: This is the correct answer. Pantoprazole is a proton pump inhibitor (PPI) that reduces gastric acid secretion. It is commonly prescribed in acute pancreatitis to decrease gastric acid production and reduce pancreatic enzyme activity, thereby promoting pancreatic rest and reducing further pancreatic inflammation and injury.
C. Initiate a low-residue diet: In acute pancreatitis, clients are typically kept NPO (nothing by mouth) initially to allow the pancreas to rest and inflammation to decrease. Once oral intake is resumed, a low-fat, easily digestible diet is usually recommended. However, the initiation of a low-residue diet is not typically indicated during the acute phase of pancreatitis.
D. Ambulate twice daily: While early ambulation is generally encouraged in hospitalized clients to prevent complications such as deep vein thrombosis and pneumonia, ambulation may be limited initially in clients with acute pancreatitis due to pain and discomfort. Ambulation is not typically a priority during the acute phase of pancreatitis; instead, pain management and supportive care are emphasized.

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A nurse is planning to administer olanzapine 10 mg IM to a client who has schizophrenia. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["C","D","E"]

Explanation

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Correct Answer is B

Explanation

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