A nurse is assisting in the care of a client.

For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Check deep tendon reflexes.

Discontinue fluoxetine.

Administer citalopram.

Administer phenelzine.

Administer propranolol.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Check deep tendon reflexes: The client exhibits restlessness, diaphoresis, tachycardia, elevated temperature, and gastrointestinal symptoms, which are consistent with serotonin syndrome. Hyperreflexia and clonus are key neuromuscular findings associated with this condition. Assessing deep tendon reflexes helps confirm neuromuscular hyperactivity.
Discontinue fluoxetine: Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) that increases serotonin levels and can precipitate serotonin syndrome. The client’s symptoms developed after initiating this medication, suggesting toxicity. Immediate discontinuation removes the source of excess serotonin.
Administer citalopram: Citalopram is another SSRI that increases serotonin activity. Administering it while the client is experiencing serotonin toxicity would worsen the condition. Adding another serotonergic agent could intensify hyperthermia, autonomic instability, and neuromuscular symptoms.
Administer phenelzine: Phenelzine is a monoamine oxidase inhibitor (MAOI) that significantly increases serotonin levels. Combining or switching to an MAOI in the setting of suspected serotonin syndrome is dangerous and can precipitate severe toxicity. MAOIs require a washout period after SSRIs due to fluoxetine’s long half-life.
Administer propranolol: Propranolol may be used to manage autonomic instability such as tachycardia and hypertension associated with serotonin syndrome. The client’s elevated heart rate and blood pressure support this intervention. Controlling sympathetic overactivity reduces cardiovascular strain.

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Correct Answer is C

Explanation

A. "The feeding should last 5 to 10 minutes.": Newborn feedings usually take 20 to 30 minutes, depending on the baby’s sucking strength and tolerance. A 5–10 minute feeding is typically too short for adequate intake.

B. "My baby should be burped prior to feeding.": Burping is recommended during and after feeding, not before. Burping helps release swallowed air and reduce discomfort, so this statement shows a misunderstanding.

C. "My baby might spit up a small amount of formula while feeding.": It is normal for newborns to regurgitate small amounts of formula due to an immature lower esophageal sphincter and active feeding. Recognizing this as typical demonstrates correct understanding of bottle-feeding expectations.

D. "The opening of the nipple should be enlarged.": The nipple hole should be appropriately sized to allow slow, controlled flow of formula. Enlarging the opening can cause choking, gagging, or overfeeding.

A. The formula infusion rate of the feeding was too slow. B. The formula was given immediately following removal from the refrigerator. C. The feeding tube was partially obstructed during the infusion. D. The client is experiencing delayed gastric emptying.

Correct Answer is B

Explanation

A. The formula infusion rate of the feeding was too slow: A slow infusion rate generally decreases the risk of diarrhea because the gastrointestinal tract has more time to absorb nutrients. Rapid administration is more commonly associated with osmotic diarrhea due to overwhelming intestinal absorption capacity, so a slow rate is an unlikely cause.

B. The formula was given immediately following removal from the refrigerator: Cold formula can irritate the gastrointestinal mucosa and disrupt normal digestive enzyme activity, leading to increased motility and diarrhea. Allowing the formula to reach room or body temperature before administration helps reduce gastric upset and osmotic diarrhea.

C. The feeding tube was partially obstructed during the infusion: Partial obstruction typically slows or interrupts the flow of formula, which may cause bloating or nausea but does not usually result in diarrhea. The decreased delivery rate reduces intestinal osmotic load rather than triggering loose stools.

D. The client is experiencing delayed gastric emptying: Delayed gastric emptying slows the passage of formula into the small intestine, which can cause nausea, vomiting, or reflux, but it does not commonly cause diarrhea. Diarrhea is more associated with rapid gastric emptying or malabsorption rather than delayed emptying.

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A nurse is assisting in the care of a client. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about bottle feeding techniques with the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has a gastrostomy tube and is experiencing diarrhea. Which of the following factors should the nurse identify as a potential cause of the diarrhea?

Correct Answer is B

Explanation

A nurse is expressing concern about his assignment with the charge nurse. The nurse states that he has more work to do than anyone else. Which of the following statements by the charge nurse demonstrates the conflict resolution strategy of competing?

A nurse is reinforcing teaching with a client about caring for a new colostomy. Which of the following statements should the nurse make?

A nurse is reinforcing teaching about smoking cessation with a client who has chronic bronchitis and has smoked two packs of cigarettes per day for 30 years. Which of the following client statements indicates an understanding of the teaching?

A nurse is caring for a client who has a new prescription for furosemide and asks the nurse about the purpose of the medication. The nurse states, "This medication is a diuretic that removes excess fluid from your body." Which of the following ethical concepts is the nurse exhibiting?

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A nurse is assisting in the preparation of an in-service for a group of unit nurses about ethical principles. Which of the following nursing actions should the nurse include as an example of fidelity?

A nurse is assisting with planning care for a newborn who is experiencing neonatal abstinence syndrome. Which of the following findings should the nurse expect?

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A nurse is assisting in the care of a client.

For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.