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The nurse continues to care for the client.
Exhibits
The nurse administers the client's scheduled medication. Which of the following adverse effects of the medication should the nurse monitor the client for? Select all that apply.

Sudden muscular contractions

Orthostatic hypotension

Anticholinergic effects

Tremors

Sedation

Increased urination

Answer and Explanation

Correct Answer : A,B,C,D,E

Rationale:

A. Sudden muscular contractions: Antipsychotics like haloperidol and chlorpromazine can cause extrapyramidal symptoms (EPS), including acute dystonia, which manifests as sudden, involuntary muscle contractions typically affecting the face, neck, or back.

B. Orthostatic hypotension: Chlorpromazine, a low-potency typical antipsychotic, often causes orthostatic hypotension due to its alpha-adrenergic blockade, increasing fall risk, especially in older adults or those new to therapy.

C. Anticholinergic effects: These include dry mouth, blurred vision, constipation, and urinary retention. Chlorpromazine is particularly known for its anticholinergic side effects due to its action on muscarinic receptors.

D. Tremors: Tremors are part of parkinsonian side effects, another form of EPS commonly caused by haloperidol. They result from dopamine blockade in the nigrostriatal pathway.

E. Sedation: Both haloperidol and chlorpromazine can cause sedation. Chlorpromazine is especially sedating due to its histamine (H1) receptor blockade, which depresses the CNS.

F. Increased urination: Not typically associated with these medications. In fact, anticholinergic effects from chlorpromazine more often lead to urinary retention, not increased urination.

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Correct Answer is C

Explanation

Rationale:

A. Pain level of 1 on a scale of 0 to 10: A low pain score suggests effective pain management and is not associated with poor wound healing. In fact, well-controlled pain can facilitate mobility and participation in recovery activities, both of which support healing.

B. Capillary refill time 1 second: This finding reflects good peripheral perfusion, indicating adequate circulation and oxygen delivery to tissues, which are essential for optimal wound healing.

C. BMI 35: A BMI of 35 indicates obesity, which is a known risk factor for delayed wound healing. Excess adipose tissue reduces vascularity, increases tension on wound edges, and raises the risk of infection and dehiscence.

D. Oxygen saturation 97% on room air: Normal oxygen saturation ensures tissues are receiving sufficient oxygen to support cellular repair and regeneration. This value supports wound healing rather than delaying it.

A. Clamp the chest tube every 2 hr to assess the amount of drainage. B. Add water to the water seal chamber as it evaporates. C. Mark the drainage output on the collection chamber. D. Maintain the collection chamber above the level of the client's waist. E. Strip the chest tube vigorously to dislodge blood clots.

Correct Answer is ["B","C"]

Explanation

Rationale:

A. Clamp the chest tube every 2 hr to assess the amount of drainage: Clamping a chest tube is not routine and can lead to tension pneumothorax by preventing air or fluid from escaping the pleural space. It should only be done briefly and under specific provider direction.

B. Add water to the water seal chamber as it evaporates: Water in the water seal chamber may evaporate over time and should be maintained at the prescribed level to preserve the one-way seal. This ensures proper functioning of the chest drainage system.

C. Mark the drainage output on the collection chamber: Marking the drainage level at regular intervals allows for accurate monitoring of output trends, which can help detect complications like hemorrhage or increased fluid accumulation.

D. Maintain the collection chamber above the level of the client's waist: The collection chamber should be kept below the level of the chest to promote gravity drainage. Elevating it above the waist can allow fluid or air to flow back into the pleural space.

E. Strip the chest tube vigorously to dislodge blood clots: Stripping is not recommended as it creates high negative pressure that may damage lung tissue. If clots are suspected, milking the tube gently or other interventions should be discussed with the provider.

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The nurse continues to care for the client.Exhibits The nurse administers the client's scheduled medication. Which of the following adverse effects of the medication should the nurse monitor the client for? Select all that apply.

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Correct Answer is C

Explanation

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Correct Answer is ["B","C"]

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The nurse continues to care for the client.
Exhibits
The nurse administers the client's scheduled medication. Which of the following adverse effects of the medication should the nurse monitor the client for? Select all that apply.