Exhibits

The nurse reviews the healthcare providers (HCP) prescription for clonazepam and gives the medication as prescribed.

Which nursing intervention(s) is/are appropriate for the client starting clonazepam? Select all that apply.

Assess mental status regularly

Provide oral care at least twice à day

Monitor calcium levels

Have an opioid agonist at the bedside

Assist the client to the bathroom

Screen for orthostatic hypotension

Answer and Explanation

Correct Answer : A,B,E,F

A.   Clonazepam is a benzodiazepine used primarily for anxiety disorders and can affect mental status, including cognition and level of alertness. Regular assessment helps monitor for any changes in mental status, such as drowsiness, confusion, or sedation, which are potential side effects of clonazepam.
B.   This intervention helps maintain oral hygiene, which is important when a client is taking medications orally. Benzodiazepines like clonazepam can cause dry mouth as a side effect, which can contribute to oral hygiene issues such as increased risk of dental caries or oral infections.
C.   Clonazepam itself does not directly affect calcium levels. Monitoring calcium levels is not a routine nursing intervention specifically related to clonazepam administration. This option is not appropriate in this context.
D.   Clonazepam is not an opioid and does not directly interact with opioids in a way that would necessitate having an opioid agonist at the bedside. This option is not relevant for a client starting clonazepam.
E.   Clonazepam can cause dizziness and impair coordination, especially when starting the medication or with dose changes. Assisting the client to the bathroom helps prevent falls and ensures safety, particularly if the client experiences dizziness or sedation.
F.   Benzodiazepines like clonazepam can cause hypotension (low blood pressure), which may exacerbate upon standing (orthostatic hypotension). Screening involves checking blood pressure and heart rate in different positions (lying, sitting, standing) to detect orthostatic changes. This is important to prevent falls and other complications.

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Correct Answer is []

Explanation

Potential condition: Polycythemia

Actions to take

Have the parents increase the child's caloric intake: Polycythemia in children with tetralogy of Fallot can be managed by ensuring adequate hydration and nutrition. Increasing caloric intake helps support growth and development and can prevent excessive erythrocytosis.

Take the child's vital signs: Regular monitoring of vital signs, including heart rate, respiratory rate, blood pressure, and temperature, is essential to assess the child's cardiovascular status and response to treatment.

Parameters to monitor

Oxygen saturation: Monitoring oxygen saturation helps assess the adequacy of pulmonary blood flow and oxygenation in a child with tetralogy of Fallot and polycythemia.

Weight: Monitoring weight is crucial to assess growth and nutritional status. Children with tetralogy of Fallot may have poor weight gain due to increased metabolic demands and potential feeding difficulties.

A. The pressure dressing at right femoral area is moist and oozing blood. B. Pulse distal to the femoral artery is weaker on left foot than right foot. C. Right foot is cool to the touch and appears pale and blanched. D. Blood pressure trend is downward and pulse is rapid and irregular.

Correct Answer is C

Explanation

A. While bleeding can occur postoperatively from the catheter insertion site, it is more indicative of venous or capillary bleeding rather than arterial obstruction. Arterial obstruction typically presents with signs related to decreased arterial blood flow rather than external bleeding.

B. This finding suggests a difference in peripheral pulses between the two lower extremities. While it could indicate arterial compromise, the question specifically asks about arterial obstruction at the site of the catheterization (right femoral artery).

C. This finding is concerning for arterial obstruction. Coolness, pallor, and blanching of the right foot indicate decreased arterial blood flow to the extremity. Arterial obstruction can lead to reduced perfusion distal to the occlusion site, resulting in these clinical signs.

D. These vital sign changes could indicate systemic complications, such as shock, rather than isolated arterial obstruction at the femoral artery site. While systemic changes can occur secondary to arterial obstruction, they are not specific indicators of obstruction at the femoral artery.

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Exhibits The nurse reviews the healthcare providers (HCP) prescription for clonazepam and gives the medication as prescribed. Which nursing intervention(s) is/are appropriate for the client starting clonazepam? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

Actions to take

Parameters to monitor

The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

Correct Answer is C

Explanation

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

A client with septic shock develops disseminated intravascular coagulation (DIC). Which pathophysiologic process should the nurse recognize as the cause of the coagulation problem?

A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPS. Which intervention should the home health nurse implement to ensure adequate care for all clients?

The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

A client admitted with pneumonia and on bedrest has not had the strength to perform self care. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

Exhibits

The nurse reviews the healthcare providers (HCP) prescription for clonazepam and gives the medication as prescribed.

Which nursing intervention(s) is/are appropriate for the client starting clonazepam? Select all that apply.