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 B

Explanation

A. The client who has a chest tube to water seal: A chest tube to water seal is primarily used to drain air or fluid from the pleural space. While the client with a chest tube may experience electrolyte imbalances due to fluid loss, hypokalemia is not directly associated with this type of drainage system.
B. The client who has a nasogastric (NG) tube to suction: Clients with nasogastric tubes to suction may experience hypokalemia due to the loss of gastric contents, which contain potassium. Suctioning removes gastric secretions, including potassium, from the body, leading to the risk of electrolyte imbalances such as hypokalemia.
C. The client who has an indwelling urinary catheter to gravity drainage: Gravity drainage of urine via an indwelling urinary catheter does not typically lead to significant potassium loss. While urinary catheterization may carry a risk of electrolyte imbalances over time, it is not as directly associated with hypokalemia as suctioning gastric contents.
D. The client who has a tracheostomy tube attached to humidified oxygen: Humidified oxygen delivery through a tracheostomy tube does not directly affect potassium levels. While clients receiving oxygen therapy may have other respiratory-related issues, hypokalemia is not typically a concern related to this type of therapy.

A. Confine the fire B. Rescue the clients C. Pull the fire alarm D. Extinguish the fire.

Correct Answer is B, C, A, D

Explanation

Answer: B, C, A, D Rationale: B (Rescue the clients): The immediate priority in any fire situation is to ensure the safety of individuals, which includes removing clients from danger. C (Pull the fire alarm): After clients are safe, the next step is to alert others of the fire and call for assistance. A (Confine the fire): Once the alarm is activated, the fire should be contained by closing doors or windows to prevent it from spreading. D (Extinguish the fire): If it is safe to do so, the fire should be extinguished using the appropriate equipment. If not, evacuation is the next step.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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