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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Relieve the client's pain: While pain management is important for client comfort and recovery, it is not the priority immediately following intermaxillary fixation. Pain relief can be addressed once the more urgent concerns, such as preventing aspiration, are addressed.
B. Promote oral hygiene: Promoting oral hygiene is essential for preventing complications such as infection, but it is not the priority immediately after surgery and intermaxillary fixation. The client's airway and respiratory status should be the primary focus at this time.
C. Ensure adequate nutrition: Ensuring adequate nutrition is important for the client's overall recovery, but it is not the immediate priority after surgery and intermaxillary fixation. The priority is to prevent complications such as aspiration and maintain the client's airway.
D. Prevent aspiration: This is the priority action for the nurse. Intermaxillary fixation restricts the client's ability to open their mouth, increasing the risk of aspiration if vomiting occurs. The nurse should ensure that the client's airway is clear and that measures are in place to prevent aspiration, such as positioning the client appropriately and monitoring for signs of respiratory distress.
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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