Exhibits

The nurse reviews the healthcare providers (HCP) prescription for clonazepam and gives the medication as prescribed.

Which nursing intervention(s) is/are appropriate for the client starting clonazepam? Select all that apply.

Assess mental status regularly

Provide oral care at least twice à day

Monitor calcium levels

Have an opioid agonist at the bedside

Assist the client to the bathroom

Screen for orthostatic hypotension

Answer and Explanation

Correct Answer : A,B,E,F

A.   Clonazepam is a benzodiazepine used primarily for anxiety disorders and can affect mental status, including cognition and level of alertness. Regular assessment helps monitor for any changes in mental status, such as drowsiness, confusion, or sedation, which are potential side effects of clonazepam.
B.   This intervention helps maintain oral hygiene, which is important when a client is taking medications orally. Benzodiazepines like clonazepam can cause dry mouth as a side effect, which can contribute to oral hygiene issues such as increased risk of dental caries or oral infections.
C.   Clonazepam itself does not directly affect calcium levels. Monitoring calcium levels is not a routine nursing intervention specifically related to clonazepam administration. This option is not appropriate in this context.
D.   Clonazepam is not an opioid and does not directly interact with opioids in a way that would necessitate having an opioid agonist at the bedside. This option is not relevant for a client starting clonazepam.
E.   Clonazepam can cause dizziness and impair coordination, especially when starting the medication or with dose changes. Assisting the client to the bathroom helps prevent falls and ensures safety, particularly if the client experiences dizziness or sedation.
F.   Benzodiazepines like clonazepam can cause hypotension (low blood pressure), which may exacerbate upon standing (orthostatic hypotension). Screening involves checking blood pressure and heart rate in different positions (lying, sitting, standing) to detect orthostatic changes. This is important to prevent falls and other complications.

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Correct Answer is C

Explanation

Rationale

A. After a cystoscopy, clients typically do not need to lay prone (face down) for an extended period. They are usually allowed to resume normal activities fairly soon after the procedure.

B. This instruction is important because iodine-based contrast agents are commonly used during cystoscopy procedures to enhance visualization of the urinary tract. Clients with allergies to shellfish (due to potential cross-reactivity with iodine) or iodine itself should be identified to avoid allergic reactions. This allows the healthcare team to take appropriate precautions and possibly use alternative agents if needed.

C. This instruction is crucial for monitoring post-procedure complications. Painful urination, blood in urine (hematuria), and fever can indicate infection or other complications following a cystoscopy. Prompt reporting allows for early intervention and treatment if necessary.

D. This instruction is not typically necessary after a cystoscopy. Most clients can resume normal activities, including light exercise, shortly after the procedure. Avoiding strenuous activity for two weeks would be excessive and not aligned with typical post-cystoscopy recovery guidelines.

A. Report the complaint of eye pain to the surgeon. B. Begin postoperative prophylactic antibiotics. C. Apply bilateral eye shields to reduce photosensitivity. D. Administer an antiemetic to prevent vomiting.

Correct Answer is A

Explanation

Rationale

A. Acute pain following laser trabeculoplasty could indicate increased intraocular pressure, inflammation, or other complications. Reporting the pain to the surgeon allows for prompt evaluation and intervention, which may include further assessment of intraocular pressure, examination of the surgical site, and consideration of additional treatment modalities such as pain management or anti- inflammatory medications.

B. Postoperative antibiotics are typically prescribed to prevent infection after surgery. However, acute pain alone may not indicate an infection, and starting antibiotics without assessing the cause of pain could delay appropriate management. Antibiotics are not indicated as the first-line response to acute pain in this context.

C. Eye shields are commonly used after eye surgery to protect the eye from light and potential trauma. While important for protecting the eye, applying eye shields addresses a different aspect of postoperative care (protecting the eye from external factors), rather than addressing the acute pain reported by the client.

D. Nausea and vomiting can sometimes occur postoperatively due to anesthesia or medications. However, administering an antiemetic is not the appropriate action in response to acute eye pain following laser trabeculoplasty. It does not address the underlying cause of the pain and is not part of the standard immediate management for this situation.

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Exhibits The nurse reviews the healthcare providers (HCP) prescription for clonazepam and gives the medication as prescribed. Which nursing intervention(s) is/are appropriate for the client starting clonazepam? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?

Correct Answer is C

Explanation

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?

Correct Answer is A

Explanation

The nurse is assessing a 3-month-old client who had a pyloromyotomy yesterday. This child should be medicated for pain based on which finding(s)? Select all that apply.

Exhibits Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.

The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

When developing a teaching plan for a client with newly diagnosed type 1 diabetes mellitus, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

Exhibits

The nurse reviews the healthcare providers (HCP) prescription for clonazepam and gives the medication as prescribed.

Which nursing intervention(s) is/are appropriate for the client starting clonazepam? Select all that apply.