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Exhibits

The nurse reviews the physician's orders for clonazepam and gives the medication as ordered. What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.

Screen for orthostatic hypotension

Provide oral care at least twice a day

Monitor calcium levels

Assess mental status regularly

Assist the client to the bathroom

Have an opioid agonist at the bedside

Answer and Explanation

Correct Answer : A,B,D,E

Nursing Interventions for Client Starting Clonazepam:

The following nursing interventions are appropriate for the client starting clonazepam 0.25 mg PO every 12 hours:

a. Screen for orthostatic hypotension:

Rationale:

Clonazepam, like other benzodiazepines, can cause central nervous system (CNS) depression, which can lead to hypotension, particularly orthostatic hypotension. This occurs when blood pressure drops suddenly upon standing due to impaired autonomic nervous system regulation.
Screening for orthostatic hypotension involves measuring the client's blood pressure and heart rate while lying down and then again after standing for 3 minutes. A significant drop in blood pressure (systolic decrease of 20 mmHg or diastolic decrease of 10 mmHg) or increase in heart rate (over 20 beats per minute) indicates orthostatic hypotension.
Monitoring for orthostatic hypotension is crucial to prevent falls and other complications, especially in older adults or those with pre-existing cardiovascular conditions.

b. Provide oral care at least twice a day:

Rationale:

Clonazepam can cause dry mouth as a side effect, which can increase the risk of cavities, gum disease, and oral infections.
Regular oral care helps to remove plaque and bacteria, promoting oral hygiene and preventing complications. Providing oral care at least twice a day, especially before bedtime and upon waking, is essential.

d. Assess mental status regularly:

Rationale:

Clonazepam, while indicated for anxiety and insomnia, can paradoxically cause agitation, confusion, and even hallucinations in some individuals, particularly older adults or those with pre-existing psychiatric conditions.
Regular assessment of mental status helps to identify any adverse behavioral or cognitive changes early on. This includes monitoring for anxiety, depression, suicidal ideation, confusion, disorientation, hallucinations, and changes in sleep patterns.

e. Assist the client to the bathroom:

Rationale:

Clonazepam can cause drowsiness and dizziness, which can increase the risk of falls, especially in older adults or those with impaired mobility.
Assisting the client to the bathroom and providing support during toileting activities helps to prevent falls and injuries.

Choices not included:

c. Monitor calcium levels:

There is no specific indication for monitoring calcium levels with clonazepam use.

f. Have an opioid agonist at the bedside:

Clonazepam is not indicated for pain management and does not interact significantly with opioid analgesics. Therefore, having an opioid agonist readily available is not a necessary intervention for clonazepam initiation.

Additional Considerations:

Educate the client about the potential side effects of clonazepam, including drowsiness, dizziness, dry mouth, and cognitive changes.
Advise the client to avoid alcohol and other CNS depressants while taking clonazepam, as this can increase the risk of sedation and respiratory depression.
Instruct the client to take clonazepam exactly as prescribed and not to stop taking it abruptly, as this can lead to withdrawal symptoms.
Monitor the client's sleep patterns and adjust the medication schedule if necessary.

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Correct Answer is B

Explanation

Administering a large volume of medication in a single injection is not recommended for infants as it can lead to discomfort, tissue trauma, and potential complications such as muscle fibrosis or nerve injury. Dividing the medication into two injections with volumes under 1 mL is a common practice for infants and can help minimize discomfort and complications.

In addition, the nurse should select an appropriate needle size and injection site based on the infant's size and age. A 22 gauge 1 1/2 inch (3.8 cm) needle is too large for an infant and may cause discomfort and tissue damage. The nurse should use a smaller gauge needle and choose an appropriate injection site, such as the vastus lateralis muscle in the thigh or the dorsogluteal muscle in the buttocks, based on the infant's age and size.

Finally, administering an injection into the deltoid muscle is not recommended for infants as this muscle is not fully developed until later in childhood. Using a quick dart-like motion to inject into the dorsogluteal site is also not recommended as it can cause tissue damage and discomfort. Instead, the nurse should use a slow, steady technique to administer the injection while ensuring the infant is held securely by the parent or another caregiver.

A. Palpate all peripheral pulse points for volume and strength. B. Monitor the amount of drainage from the client's incision. C. Observe both lower extremities for redness and swelling. D. Evaluate the client's ability to use an incentive spirometer.

Correct Answer is C

Explanation

The correct answer is choice C. Observe both lower extremities for redness and swelling.

Choice A rationale:

Palpating all peripheral pulse points for volume and strength is important for assessing circulation, but it does not directly evaluate the effectiveness of intermittent pneumatic compression (IPC) devices.IPC devices are primarily used to prevent deep vein thrombosis (DVT) and improve venous return, so monitoring for signs of DVT is more relevant.

Choice B rationale:

Monitoring the amount of drainage from the client’s incision is crucial for assessing wound healing and detecting potential infections, but it is not related to the effectiveness of IPC devices.

Choice C rationale:

Observing both lower extremities for redness and swelling is the most important assessment for evaluating the effectiveness of IPC devices. Redness and swelling can be signs of DVT, which IPC devices are designed to prevent.Therefore, this assessment directly measures whether the devices are functioning as intended.

Choice D rationale:

Evaluating the client’s ability to use an incentive spirometer is important for preventing postoperative pulmonary complications, but it does not assess the effectiveness of IPC devices.

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Exhibits The nurse reviews the physician's orders for clonazepam and gives the medication as ordered. What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.

Nursing Interventions for Client Starting Clonazepam:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer 1.6 mL of medication intramuscularly to a 4-month-old infant. Which action should the nurse include?

Correct Answer is B

Explanation

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

Correct Answer is C

Explanation

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Exhibits

The nurse reviews the physician's orders for clonazepam and gives the medication as ordered. What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.