A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath and is difficult to arouse. When performing a head to toe assessment, the nurse discovers four analgesic patches on the client's body. Which intervention should the nurse implement first?

Measure the client's blood pressure.

Remove all of the morphine patches.

Apply oxygen per face mask.

Administer a narcotic antagonist.

Answer and Explanation

The Correct Answer is D

A. Measure the client's blood pressure:
While monitoring blood pressure is an important aspect of assessing a client's overall condition, it is not the immediate priority in a suspected opioid overdose. Respiratory depression and difficulty in arousing are more critical concerns that warrant prompt intervention with naloxone.

B. Remove all of the morphine patches:
While eventually, the nurse will need to address the presence of multiple morphine patches, removing them is not the first action. Administering naloxone to reverse the opioid effects takes precedence over patch removal.

C. Apply oxygen per face mask:
While providing oxygen may be necessary to support respiratory function, it doesn't address the underlying cause of the respiratory distress, which is likely opioid toxicity. Administering naloxone is the more direct and immediate intervention to counteract the effects of the opioids.

D. Administer a narcotic antagonist:
This is the correct and immediate priority. If the client is difficult to arouse and has multiple morphine patches, it raises concerns about opioid toxicity. Naloxone is a narcotic antagonist that can reverse the effects of opioid overdose, particularly respiratory depression, and is crucial in this scenario to restore normal respiratory function.

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Correct Answer is C

Explanation

A. Facial puffiness and periorbital edema:
These are common signs of hypothyroidism but may not require immediate action unless accompanied by severe symptoms.

B. Cold and dry skin:
Cold and dry skin is a characteristic feature of hypothyroidism, but a further decline in the level of consciousness is a more urgent issue.

C. Further decline in the level of consciousness.
A decline in the level of consciousness is a critical sign that requires immediate attention, as it may indicate worsening hypothyroidism, myxedema coma, or other serious complications. Myxedema coma is a life-threatening condition associated with severe hypothyroidism, and it requires prompt medical intervention.

D. Hematocrit of 30% (0.30):
While anemia is a potential complication of hypothyroidism, a hematocrit of 30% alone may not be the most immediate concern compared to a decline in the level of consciousness.

A. Jugular vein distention. B. Carotid bruit. C. Nuchal rigidity. D. Palpable cervical lymph node.

Correct Answer is B

Explanation

A. Jugular vein distention:
Jugular vein distention is not typically associated with an increased risk of a stroke. It may be indicative of issues related to cardiac or fluid volume status.

B. Carotid bruit:
This is the correct answer. A carotid bruit, an abnormal sound caused by turbulent blood flow through the carotid artery, may indicate the presence of atherosclerosis and increased risk of stroke. It suggests a narrowing or blockage in the carotid artery, which can potentially lead to emboli and subsequent stroke.

C. Nuchal rigidity:
Nuchal rigidity, stiffness of the neck, is associated with conditions such as meningitis but is not a direct risk factor for a stroke.

D. Palpable cervical lymph node:
Palpable cervical lymph nodes may be indicative of infection or inflammation in the head and neck region but are not directly associated with an increased risk of a stroke.

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A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath and is difficult to arouse. When performing a head to toe assessment, the nurse discovers four analgesic patches on the client's body. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has a history of hypothyroidism was initially admitted with lethargy and confusion Which additional finding warrants the most immediate action by the nurse?

Correct Answer is C

Explanation

The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?

Correct Answer is B

Explanation

A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?

A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath and is difficult to arouse. When performing a head to toe assessment, the nurse discovers four analgesic patches on the client's body. Which intervention should the nurse implement first?

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