A nurse is teaching a client who has a new prescription for sertraline to treat depression. For which of the following findings should the nurse instruct the client to monitor and report immediately as indicating serotonin syndrome?
Dry mouth
Constipation
Insomnia
Excessive sweating
The Correct Answer is D
A. Dry mouth is a common side effect but not a sign of serotonin syndrome.
B. Constipation is another possible side effect but is not an emergency.
C. Insomnia can occur but does not indicate serotonin syndrome.
D. This is the correct answer. Excessive sweating (along with agitation, confusion, fever, and muscle rigidity) is a sign of serotonin syndrome, a potentially life-threatening condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Repeat the complete prescription back to the provider – This is the correct action to ensure accuracy and prevent medication errors. The nurse must read back the prescription, including the medication name, dosage, route, and frequency, for verification.
B. Have a provider who is on site sign the prescription – The prescribing provider must sign the order within a specific timeframe, but this step occurs after verifying and documenting the prescription.
C. Have the unit secretary enter the prescription on the provider's order form – Only licensed personnel (nurses, pharmacists, or providers) can transcribe and verify medication orders. The unit secretary cannot enter prescriptions.
D. Verify the accuracy of the prescription with the pharmacist – The nurse should first confirm the order with the provider, not the pharmacist. The pharmacist’s role comes after the order is documented and entered.
Correct Answer is A
Explanation
A. Heart rate 148/min – Correct. A heart rate of 148/min in a 3-year-old is elevated (tachycardia) and may indicate worsening dehydration or shock.
B. Potassium 3.9 mEq/L – Incorrect. This potassium level is within the normal range (3.5–5.0 mEq/L).
C. Respiratory rate 22/min – Incorrect. This is within the expected range for a 3-year-old.
D. Sodium 142 mEq/L – Incorrect. This sodium level is within the normal range (135–145 mEq/L).
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