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Questions 149

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Question 1 of 5

A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:

Correct Answer: D

Rationale: Severe muscle rigidity and fever suggest neuroleptic malignant syndrome (NMS), a medical emergency requiring immediate transfer to a medical unit for treatment.

Question 2 of 5

The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:

Correct Answer: C

Rationale: Epidural anesthesia can reduce bladder sensation, necessitating frequent catheterization to prevent overdistension.

Question 3 of 5

The nurse is caring for a client with a stage II sacral ulcer. Which nursing intervention would be most effective in promoting healing?

Correct Answer: C

Rationale: Increased protein and calorie intake supports tissue repair and healing for a stage II ulcer, more than heat lamps, antibiotics (unless infection is present), or wet-to-dry dressings.

Question 4 of 5

When caring for a client with an anterior cervical discectomy, the nurse should give priority to assessing for post-operative bleeding. The nurse should pay particular attention to:

Correct Answer: D

Rationale: Swelling in the posterior neck may indicate a hematoma, which can compress the airway or spinal cord, a critical post-operative complication.

Question 5 of 5

Four clients are to receive medication. Which client should receive medication first?

Correct Answer: C

Rationale: A stat dose of Lasix for labored respirations indicates an urgent need to address potential pulmonary edema, prioritizing this client.

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