Examkin

Soru

Zorluk: Çok zorPharmacological Therapies

A practical nurse is assisting with the care of a client who is prescribed scheduled oral clozapine for the management of schizophrenia. During morning data collection, the client reports a new-onset sore throat and chills. The client's vital signs are blood pressure 92/58 mmHg92/58\text{ mmHg}, heart rate 114 beats/minute114\text{ beats/minute}, respiratory rate 20 breaths/minute20\text{ breaths/minute}, and temperature 101.2∘F101.2^\circ\text{F} (38.4∘C38.4^\circ\text{C}). The morning laboratory results indicate a white blood cell (WBC) count of 2,200/mm32,200/\text{mm}^3 and an absolute neutrophil count (ANC) of 800/mm3800/\text{mm}^3. Which of the following actions should the practical nurse take? Select all that apply.

  1. Withhold the scheduled morning dose of clozapine.Cevap
  2. Notify the registered nurse immediately regarding the client's vital signs and laboratory results.Cevap
  3. Implement neutropenic precautions and ensure the client is in a private room.Cevap
  4. D
    Document the borderline vital signs as an expected, non-urgent response to the client's elevated temperature.
  5. E
    Administer the scheduled clozapine dose, as abrupt discontinuation can lead to severe withdrawal symptoms.
  6. F
    Prepare to administer a stat dose of broad-spectrum antibiotics via direct intravenous (IV) push as prescribed.

Cevap

The practical nurse should withhold the scheduled dose of clozapine, notify the registered nurse immediately, and implement neutropenic precautions.
The correct answers involve recognizing that the client is experiencing agranulocytosis (a critical adverse effect of clozapine) complicated by neutropenic fever and potential early septic shock. The practical nurse must prioritize safety by withholding the offending medication to prevent further bone marrow suppression. Because the client has an absolute neutrophil count (ANC) of 800/mm³, implementing neutropenic precautions in a private room is necessary to prevent exposure to pathogens. Furthermore, the combination of a fever, tachycardia, and borderline hypotension in an immunocompromised client indicates a medical emergency; therefore, immediately escalating these findings to the registered nurse is critical.

Adım Adım Çözüm

1
Analyze the client's laboratory results in the context of their prescribed medication.
The WBC count and ANC are critically low, indicating agranulocytosis, which is a known severe adverse effect of clozapine.
Identifying critical lab values determines if a medication is safe to administer.
2
Evaluate the client's vital signs and physical symptoms.
The client has a fever, sore throat, tachycardia, and hypotension, which collectively suggest neutropenic fever and impending septic shock.
Recognizing signs of sepsis early allows for prompt escalation and lifesaving interventions.
3
Determine the appropriate nursing interventions within the practical nurse scope of practice.
The nurse must withhold the clozapine, initiate neutropenic precautions, and urgently notify the registered nurse. Administering IV push medications must be avoided as it falls outside the practical nurse scope.
Safe practice requires acting within legal boundaries while protecting the client from immediate harm.

Anahtar Kavram

Monitoring for and responding to clozapine-induced agranulocytosis and understanding the practical nurse scope of practice in emergent situations.
Tahmini Süre:2m 30s
Bu soruyu puanla

Konular

Pharmacological Therapies

Bu konudan daha fazla soru