Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a client with bipolar disorder who is prescribed fluoxetine, an SSRI. The client has recently started taking St. John's wort on a friend's recommendation. Which nursing action is the priority to prevent a serious adverse effect?

Instruct the client to immediately discontinue St. John's wort and notify the provider due to risk of serotonin syndrome

Encourage the client to increase the fluid intake to prevent dehydration from diarrhea

Advise the client to continue St. John's wort but monitor for mild gastrointestinal side effects.

Suggest the client reduce the dose of fluoxetine while taking St. John's wort to minimize serotonin effects.

Answer and Explanation

The Correct Answer is A

A. Instruct the client to immediately discontinue St. John's wort and notify the provider due to risk of serotonin syndrome: St. John's wort can increase serotonin levels and, when combined with an SSRI like fluoxetine, significantly raises the risk of serotonin syndrome. Prompt discontinuation and provider notification are critical to prevent this potentially life-threatening adverse effect.

B. Encourage the client to increase fluid intake to prevent dehydration from diarrhea: While hydration is important, it does not address the primary risk of serotonin syndrome, which requires immediate intervention rather than supportive measures.

C. Advise the client to continue St. John's wort but monitor for mild gastrointestinal side effects: Serotonin syndrome can present with symptoms such as agitation, confusion, rapid heart rate, and hyperthermia. Monitoring for minor GI effects ignores the life-threatening risk.

D. Suggest the client reduce the dose of fluoxetine while taking St. John's wort to minimize serotonin effects: Self-adjusting SSRI doses is unsafe and may lead to subtherapeutic treatment or increased adverse effects. Dose changes must be guided by a healthcare provider, not the patient.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Calf strain:A calf strain usually presents with localized pain and mild swelling after a known injury or overuse. It is less likely to cause significant redness, unilateral swelling of one inch, or progressive pain with activity without a precipitating trauma.

B. Peripheral artery disease (PAD):PAD typically causes pain in the lower extremities with exertion (claudication) but is associated with cool, pale skin, diminished pulses, and hair loss, rather than redness, swelling, and unilateral calf enlargement.

C. Deep vein thrombosis (DVT):DVT presents with unilateral calf pain, redness, swelling, and increased calf circumference. Oral contraceptive use is a known risk factor due to increased clotting tendency, making DVT the most likely condition in this patient.

D. Cellulitis:Cellulitis presents with redness, warmth, and swelling, but it is usually associated with systemic symptoms such as fever and may not cause significant unilateral calf circumference changes. DVT should be ruled out first due to risk of pulmonary embolism.

A. "Go to the emergency room and your provider will meet you there." B. "Come to the office and we will check things out." C. "This is expected because of the way iron is broken down during digestion.” D. "What else have you been eating?”

Correct Answer is C

Explanation

A. "Go to the emergency room and your provider will meet you there.":Black stools can be a sign of gastrointestinal bleeding, but in the absence of pain, cramping, or other symptoms, emergency evaluation is not necessary. This response may cause unnecessary anxiety.

B. "Come to the office and we will check things out.":Routine office evaluation is not required for black stools caused by iron supplements when the patient is otherwise asymptomatic.

C. "This is expected because of the way iron is broken down during digestion.":
Oral iron commonly causes dark or black stools due to oxidation of iron in the gastrointestinal tract. This is a harmless and expected side effect, and the patient can be reassured while continuing therapy.

D. "What else have you been eating?":While diet can affect stool color, in this context the most likely cause is iron supplementation. Asking about diet is not necessary unless additional symptoms suggest an alternative cause.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client with bipolar disorder who is prescribed fluoxetine, an SSRI. The client has recently started taking St. John's wort on a friend's recommendation. Which nursing action is the priority to prevent a serious adverse effect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient who has been taking oral contraceptives reports to the clinic with complaints of left calf pain that worsens with activity. On assessment the nurse notices that the left calf is red and measures one inch larger than the right calf. Which condition should the nurse suspect?

Correct Answer is C

Explanation

A nurse is speaking on the phone to a client on the phone who is pregnant and taking iron supplements for iron-deficiency anemia. The client reports that her stools are black but she has no abdominal pain or cramping. Which of the following responses by the nurse is appropriate?

Correct Answer is C

Explanation

What is the nurse's role when a client experiences an adverse drug event?

A nurse is caring for a client who has a prescription for the glucocorticoid medication fluticasone propionate with an inhaler and a spacer. The client asks the nurse why a spacer is needed with the inhaler. Which of the following responses should the nurse make?

A patient is prescribed the centrally acting muscle relaxant baclofen. Which of the following instructions should the nurse include?

A nurse is caring for a client who started the SSRI fluoxetine 3 days ago and now reports feeling agitated, with muscle tremors and a temperature of 39°C (102.2°F). Upon assessment, the nurse notes hyperreflexia, tremors, and diaphoresis. What is the nurse's best initial action?

A patient in a hypertensive crisis is prescribed hydralazine. What is the primary action of hydralazine in treating hypertensive crisis?

A patient brought to the ER is unconscious and is suspected of experiencing hypoglycemia. The hyperglycemic, glucagon is delivered IM to counteract this condition. What does the nurse understand to be the pharmacologic action of this drug?

A patient with chest pain is prescribed nitroglycerin. After taking the medication the patient reports no more chest pain, but is experiencing a headache. Which medication from the choices below would the nurse anticipate the doctor to order for this new symptom?