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Questions 149

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Question 1 of 5

A client with paranoid schizophrenia has an order for Thorazine (chlorpromazine) 400 mg orally twice daily. Which of the following symptoms should be reported to the physician immediately?

Correct Answer: A

Rationale: Fever, sore throat, and weakness may indicate agranulocytosis, a serious side effect of chlorpromazine requiring immediate reporting.

Question 2 of 5

The nurse is caring for a client with a permanent tracheostomy who is able to eat. Which is the correct action by the nurse in managing this tube?

Correct Answer: D

Rationale: Deflating the cuff during meals allows normal swallowing, reducing aspiration risk, and is maintained for 1 hour post-meal.

Question 3 of 5

The nurse is discharging a client with asthma who has a prescription for zafirlukast (Accolate). Which comment by the client would indicate a need for further teaching?

Correct Answer: A

Rationale: Zafirlukast should be taken on an empty stomach for better absorption. The other statements are correct: flulike symptoms and liver monitoring are relevant, and zafirlukast is not a rescue medication.

Question 4 of 5

A 22-year-old pregnant client is diagnosed with autoimmune hemolytic anemia. The nurse anticipates immediate treatment with

Correct Answer: E

Rationale: Autoimmune hemolytic anemia in pregnancy is typically treated with corticosteroids or IVIG (containing IgG), but IgG alone isn’t administered. None of the options are correct.

Question 5 of 5

A client is receiving an opioid per patient-controlled analgesia (PCA) pump to control postoperative pain; however, when the nurse assesses the client, she finds the client is pale and hypotensive, and has a respiratory rate of 6 breaths per minute. The PCA pump record shows that the limit for maximum dosage was set far too high, resulting in an overdose. The client is very somnolent and barely responsive. What interventions does the nurse anticipate? Select all that apply.

Correct Answer: A,C,D,E

Rationale: Opioid overdose requires stopping the infusion (
A), administering naloxone (
C) to reverse effects, providing oxygen (
D) for respiratory depression, and filing an incident report (E). Discontinuing the PCA (
B) is not immediate.

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