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What nursing interventions are appropriate for a client starting clonazepam? Select all that apply.

Assist the client to the bathroom.

Have an opioid agonist at the bedside.

Provide oral care at least twice a day.

Assess mental status regularly.

Monitor calcium levels.

Screen for orthostatic hypotension.

Answer and Explanation

Correct Answer : A,D,F

Choice A rationale

Assisting the client to the bathroom is appropriate as clonazepam can cause dizziness and unsteadiness, increasing the risk of falls.

Choice B rationale

Having an opioid agonist at the bedside is not necessary for a client starting clonazepam. Clonazepam is a benzodiazepine, not an opioid.

Choice C rationale

Providing oral care at least twice a day is generally good practice for all patients, but it’s not specifically related to clonazepam use.

Choice D rationale

Assessing mental status regularly is crucial as clonazepam can cause changes in mood and behavior.

Choice E rationale

Monitoring calcium levels is not typically required for a client starting clonazepam.

Choice F rationale

Screening for orthostatic hypotension is important as clonazepam can lower blood pressure, leading to dizziness and fainting when the client stands up.

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Correct Answer is B

Explanation

Choice A rationale

While advising family members to monitor for symptoms of illness is important, it’s not the most crucial action for the nurse to take immediately after testing the patient for COVID-194.

Choice B rationale

Implementing droplet precautions, placing the patient in a private room, and keeping the door closed is the most crucial action. This helps prevent the potential spread of COVID-19 to other patients and healthcare workers.

Choice C rationale

Informing the patient to notify others about potential exposure is important, but it’s not the most crucial action immediately after testing.

Choice D rationale

Initiating an IV infusion for the administration of an antiviral drug is not the most crucial action. Antiviral medication is typically administered after a positive test result, not before.

A. Nitroglycerin. B. Aspirin. C. Morphine. D. Heparin.

Correct Answer is A

Explanation

Choice A rationale

Nitroglycerin is a medication that is commonly used to treat chest pain or angina. However, it is contraindicated in patients who have taken sildenafil (Viagra) within the last 24 hours due to the risk of severe hypotension, or low blood pressure. Sildenafil is a type of medication known as a phosphodiesterase-5 (PDE5) inhibitor, which works by relaxing the muscles in the walls of blood vessels. Nitroglycerin also works by relaxing blood vessels, so the combination of these two medications can cause a dangerous drop in blood pressure.

Choice B rationale

Aspirin is not typically withheld in patients experiencing chest pain. It is often given to patients who are suspected of having a heart attack because it works by preventing blood clots from forming and blocking the blood vessels of the heart.

Choice C rationale

Morphine is often administered to patients experiencing severe chest pain to help relieve the pain and reduce the workload of the heart. It is not typically withheld unless the patient has a known allergy or other contraindication.

Choice D rationale

Heparin is a blood thinner that is often administered to patients who are suspected of having a heart attack to prevent further blood clots from forming. It is not typically withheld unless the patient has a known allergy, other contraindication, or is at high risk of bleeding.

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What nursing interventions are appropriate for a client starting clonazepam? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A patient arrives at the emergency department experiencing chest pain after taking sildenafil.Based on the patient’s history, which medication should the nurse withhold?

Correct Answer is A

Explanation

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