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A nurse is teaching a client who has a new prescription for sertraline to treat depression. For which of the following findings should the nurse instruct the client to monitor and report immediately as indicating serotonin syndrome?

Dry mouth

Constipation

Insomnia

Excessive sweating

Answer and Explanation

The Correct Answer is D

A. Dry mouth is a common side effect but not a sign of serotonin syndrome.

B. Constipation is another possible side effect but is not an emergency.

C. Insomnia can occur but does not indicate serotonin syndrome.

D. This is the correct answer. Excessive sweating (along with agitation, confusion, fever, and muscle rigidity) is a sign of serotonin syndrome, a potentially life-threatening condition.

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Correct Answer is B

Explanation

A. Pour cool water over the client's perineum – Warm, not cool, water is more effective in relaxing the urinary sphincter to promote urination.

B. Turn on the faucets in the client's sink – The sound of running water can trigger the urge to urinate through a reflex mechanism, making this the best option.

C. Tell the client to gently stroke her lower abdomen – This is not an effective technique for stimulating urination.

D. Instruct the client to lean slightly backward – Positioning does not significantly influence urination while using a bedpan.

A. Fold the stockings at the top if they are too long. B. Remove the stockings every 24 hr. C. Massage the legs before applying the stockings. D. Measure the legs with a tape measure to determine stocking size.

Correct Answer is D

Explanation

A. Fold the stockings at the top if they are too long – Folding the stockings can create a tourniquet effect, restricting circulation and increasing the risk of complications.

B. Remove the stockings every 24 hr – Antiembolitic stockings should be removed at least every 8 hr to assess skin integrity and circulation, not just once per day.

C. Massage the legs before applying the stockings – Massaging the legs is contraindicated in clients with DVT because it can dislodge a clot, leading to a pulmonary embolism.

D. Measure the legs with a tape measure to determine stocking size – This is the correct action because improper fit can reduce effectiveness or impair circulation. The nurse should measure the client’s legs and select the appropriate size for optimal compression.

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A nurse is teaching a client who has a new prescription for sertraline to treat depression. For which of the following findings should the nurse instruct the client to monitor and report immediately as indicating serotonin syndrome?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a female client who requires bed rest and reports difficulty urinating into a bedpan. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolitic stockings. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take first?

A nurse is part of a task force planning to audit a facility's nursing units concerning adherence to hand-hygiene protocols. Which of the following steps should the task force take first?

A nurse is reviewing the laboratory results of a client who has hypothyroidism. The client's calcium level is 7.6 mg/dL. When assessing the client, which of the following findings should the nurse expect?

Exhibits for additional information about the client. There are three tabs that contain separate categories of data.)

A community health nurse is developing a plan of care for an older adult client who has type 2 diabetes mellitus and lives independently in a rural area. Which of the following interventions should the nurse include?

A nurse is caring for a 3-year-old toddler who has dehydration. Which of the following findings should the nurse report to the provider?

A nurse is caring for a client following an involuntary admission to an acute mental health facility. The client states, "I'm afraid they will give me drugs that put me to sleep." Which of the following statements should the nurse make?

A nurse is teaching a newly licensed nurse about caring for a client who has neutropenia. Which of the following instructions should the nurse include?