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 C

Explanation

A. Activate the fire alarm: While activating the fire alarm is important in alerting others to the fire, the priority is ensuring the safety of clients in the immediate vicinity. Moving clients away from the potential danger takes precedence over activating the alarm.
B. Use a fire extinguisher to put out the fire: While extinguishing the fire is necessary to prevent its spread, it should only be attempted after ensuring the safety of clients nearby. Attempting to use a fire extinguisher without first moving clients could put them at risk of injury or smoke inhalation.
C. Move any clients in the immediate vicinity: This is the priority action. Moving clients away from the potential danger of the smoldering fire helps protect them from smoke inhalation and potential burns. It ensures their safety while allowing the nurse to assess the situation and determine further actions.
D. Close the fire doors on the unit: Closing fire doors can help contain the fire and prevent its spread, but it is not the immediate priority when clients are in close proximity to the smoldering fire. Moving clients to safety should be the first action taken.

A. "Crushing the medication might cause you to have a stomachache or indigestion B. "Crushing the medication is a good idea, and I can mix it in some ice cream for you. C. Crushing is unsafe, as it destroys the ingredients in the medication. D. "Crushing the medication would release all the medication at once, rather than over time.

Correct Answer is D

Explanation

A. "Crushing the medication might cause you to have a stomachache or indigestion."
This response provides a potential adverse effect of crushing the medication but does not directly address the reason why the aspirin should not be crushed.
B. "Crushing the medication is a good idea, and I can mix it in some ice cream for you."
This response suggests a solution to the client's difficulty swallowing medication but does not address the safety or efficacy concerns associated with crushing enteric-coated aspirin.
C. "Crushing is unsafe, as it destroys the ingredients in the medication."
While crushing enteric-coated aspirin may alter its release properties, it does not necessarily "destroy" the ingredients. This statement may be too absolute and not entirely accurate.
D. "Crushing the medication would release all the medication at once, rather than over time."
This response accurately explains why enteric-coated aspirin should not be crushed. Enteric coating is designed to prevent dissolution of the medication in the stomach and instead release it in the small intestine to reduce the risk of gastric irritation or ulceration. Crushing the medication would bypass this delayed release mechanism, potentially leading to increased gastric irritation or adverse effects.

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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?

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