A nurse is planning to administer olanzapine 10 mg IM to a client who has schizophrenia. Which of the following actions should the nurse take?

Administer the medication into the deltoid muscle.

Monitor the client for at least 3 hr after the injection.

Withhold the medication if the client reports hallucinations.

Instruct the client to expect difficulty sleeping

Answer and Explanation

The Correct Answer is B

A. Administer the medication into the deltoid muscle: Olanzapine is typically administered deep into the muscle to ensure proper absorption. However, the deltoid muscle may not be the preferred site for intramuscular injections of medications like olanzapine due to the risk of hitting the underlying radial nerve. The ventrogluteal or vastus lateralis muscles are often preferred sites for IM injections to reduce the risk of nerve damage.
B. Monitor the client for at least 3 hr after the injection: After administering olanzapine IM, the nurse should monitor the client closely for at least 3 hours to assess for any adverse reactions or side effects, such as sedation, hypotension, or extrapyramidal symptoms. This allows for early detection and prompt intervention if needed.
C. Withhold the medication if the client reports hallucinations: Olanzapine is an antipsychotic medication commonly used to treat schizophrenia and other psychotic disorders. Hallucinations are a symptom of schizophrenia, and olanzapine is often prescribed to help manage such symptoms. Withholding the medication solely based on the client reporting hallucinations would not be appropriate without further assessment and consideration of the overall treatment plan.
D. Instruct the client to expect difficulty sleeping: While olanzapine can cause sedation and may affect sleep patterns in some individuals, it is not a universal side effect for everyone. Providing anticipatory guidance about potential side effects is essential, but instructing the client to expect difficulty sleeping without individual assessment may lead to unnecessary anxiety or concerns.

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Correct Answer is D

Explanation

A. The AP's ability to complete the task without assistance: While it's important for the AP to be able to complete the task independently, this is not the only consideration when delegating tasks. The nurse should also consider whether the AP has the necessary knowledge and skill to perform the task safely and effectively.
B. The AP's rapport with clients: Although the AP's rapport with clients is valuable in providing care, it is not directly related to the ability to perform a delegated task. The nurse should prioritize delegation based on the AP's competency and skill level rather than their interpersonal skills.
C. The AP’s ability to prioritize: While the AP's ability to prioritize tasks is important in providing efficient care, it is not specifically related to the nurse's consideration when delegating tasks. Delegation decisions should primarily be based on the AP's knowledge and skill to perform the task safely and effectively.
D. The AP has the knowledge and skill to perform the task: This is the most appropriate consideration when delegating tasks. Ensuring that the AP has the necessary knowledge and skill to perform the delegated task safely and effectively is essential for patient safety and quality care. The nurse should assess the AP's competency and provide appropriate supervision and guidance as needed.

A. Hypocalcemia B. Diuretic use C. Family history D. BMI less than 25

Correct Answer is C

Explanation

A. Hypocalcemia: Hypocalcemia, or low levels of calcium in the blood, is not typically associated with an increased risk of urolithiasis. In fact, hypercalcemia, or high levels of calcium, is more commonly linked to the formation of calcium-based kidney stones.
B. Diuretic use: Diuretic medications can increase urine production and may contribute to dehydration, which can predispose individuals to the formation of kidney stones. However, diuretic use alone is not as significant a risk factor as other factors like dehydration or specific dietary habits.
C. Family history: Family history of urolithiasis is a significant risk factor for developing kidney stones. Genetic factors can influence the likelihood of stone formation, and individuals with a family history of kidney stones are at a higher risk of experiencing them themselves.
D. BMI less than 25: Obesity and higher BMI (body mass index) are associated with an increased risk of urolithiasis. Excess body weight can lead to metabolic changes that promote the formation of kidney stones. Therefore, having a BMI less than 25 is less likely to be a risk factor compared to having a higher BMI.

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A nurse is planning to administer olanzapine 10 mg IM to a client who has schizophrenia. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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