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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Yellow-green drainage from a surgical incision may indicate the presence of infection, especially if the drainage is purulent. This finding should be reported to the provider promptly for further evaluation and management to prevent complications such as wound infection or dehiscence.

A. Yellow-green drainage on the surgical incision: Yellow-green drainage suggests the presence of infection, which is a concerning finding in a postoperative client. It may indicate purulent drainage, which requires further assessment and possibly treatment with antibiotics.
B. Blood pressure 102/66 mm Hg: A blood pressure of 102/66 mm Hg is within the normal range for an adult client and does not typically require immediate intervention. However, trends in blood pressure should be monitored, especially if the client is symptomatic or if there are significant changes from the client's baseline.
C. Straw-colored urine from an indwelling urinary catheter: Straw-colored urine is a normal finding and indicates adequate hydration and kidney function. As long as the urine output is adequate and there are no other signs of urinary tract issues, this finding does not typically require immediate reporting.
D. Respiratory rate 18/min: A respiratory rate of 18 breaths per minute is within the normal range for an adult client and does not typically require immediate intervention. However, it's important to assess the client's respiratory status comprehensively, including oxygen saturation and lung sounds, to ensure adequate ventilation.

Correct Answer is ["2"]

Explanation

Here's how we can find the desired flow rate:

Total volume to infuse (in minutes):
- We need to convert the infusion time from hours to minutes.
- Time (minutes) = Time (hours) x 60 minutes/hour
- Time (minutes) = 2 hours x 60 minutes/hour
- Time (minutes) = 120 minutes
Total volume to infuse (in mL):
- Given volume = 250 mL
Drop factor (gtts/mL):
- Given drop factor = 15 gtts/mL
Flow rate (gtts/minute):
- Flow rate = Total volume (mL) / Time (minutes) x Drop factor (gtts/mL)
- Flow rate = 250 mL / 120 minutes x 15 gtts/mL

To simplify the calculation, we can divide all values by 5 (as long as we perform the division on both sides of the equation, the answer won't change):

Flow rate = (250 mL / 5) / (120 minutes / 5) x (15 gtts/mL / 5)
Flow rate = 50 mL / 24 minutes x 3 gtts/mL
Flow rate = 2.0833... gtts/minute (round to nearest whole number)

Rounded flow rate (gtts/minute):
- Flow rate = 2 gtts/minute

Therefore, the nurse should adjust the flow rate to deliver approximately 2 gtts/minute.

View Question and Answer

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

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

A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

Correct Answer is ["2"]

Explanation

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

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?

A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take?

A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority?

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?