A nurse is caring for a client diagnosed with stage 4 cancer who has a prescription for a subcutaneous morphine sulfate patch for pain.
The client is short of breath and difficult to arouse.
During a head-to-toe assessment, the nurse finds four patches on the client’s body. What should be the nurse’s first action?

Administer a narcotic reversal drug.

Apply an oxygen face mask.

Remove the morphine patches.

Monitor the client’s blood pressure.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Administering a narcotic reversal drug is not the first action the nurse should take. While it’s true that the client’s symptoms could be due to opioid overdose, the nurse should first confirm the cause of the symptoms. In this case, the nurse finds four patches on the client’s body, which is unusual and could lead to an overdose. Therefore, the first action should be to remove the patches to prevent further absorption of the drug.

Choice B rationale

Applying an oxygen face mask might be necessary if the client is having difficulty breathing. However, this would not address the underlying problem if the client is experiencing an overdose from the morphine sulfate patches. The nurse should first remove the patches to stop further drug absorption.

Choice C rationale

The nurse finds four patches on the client’s body. This is unusual and could lead to an overdose. Therefore, the nurse’s first action should be to remove the patches to prevent further absorption of the drug. After removing the patches, the nurse can assess the client’s condition and provide further interventions as needed.

Choice D rationale

Monitoring the client’s blood pressure is an important nursing intervention, but it should not be the first action in this situation. The nurse has already found a potential cause for the client’s symptoms (i.e., the four morphine sulfate patches). Therefore, the first action should be to address this problem by removing the patches.

Nursing Test Bank

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Correct Answer is D

Explanation

Choice A rationale

While a coronary artery bypass procedure is a significant event in a patient’s medical history, it occurred in 1995, which is quite some time ago. Therefore, it may not be the most significant piece of data when planning this client’s care, given their current signs and symptoms.

Choice B rationale

A colonoscopy performed for routine screening six months ago is unlikely to be related to the client’s current symptoms of nausea, vomiting, and anorexia. Therefore, this choice is not the most significant piece of data when planning this client’s care.

Choice C rationale

Depression following the death of a spouse can significantly impact a person’s mental health. However, this event occurred in 1999, and while it may contribute to the client’s overall health status, it is not likely to be the most significant piece of data for planning care based on the client’s current symptoms.

Choice D rationale

The client has been taking digoxin and furosemide daily since 19962. Both of these medications are used to treat heart conditions. Digoxin strengthens the heart’s contractions, while furosemide is a diuretic that helps reduce fluid buildup. Given the client’s symptoms of nausea, vomiting, and anorexia, and their diagnosis of heart failure, this information is crucial. These symptoms could indicate a worsening of heart failure or side effects of the medication, which would significantly influence the plan of care.

A. Hypertension. B. Bronchitis. C. Diarrhea. D. Edema.

Correct Answer is A

Explanation

Choice A rationale

Hypertension is a condition that should be reported to the healthcare provider before administering phenylephrine. Phenylephrine is a decongestant used to relieve nasal discomfort caused by colds, allergies, and hay fever. It works by shrinking swollen nasal mucous membranes, which relieves nasal congestion. However, it can cause a rise in blood pressure, which could be dangerous for patients with hypertension.

Choice B rationale

Bronchitis is not a contraindication for phenylephrine. However, if the patient has a chronic respiratory condition like bronchitis, it’s always a good idea to discuss any new medications with the healthcare provider.

Choice C rationale

Diarrhea is not a contraindication for phenylephrine. Phenylephrine is not known to cause or worsen diarrhea.

Choice D rationale

Edema is not a contraindication for phenylephrine. However, if the patient has a history of heart disease or high blood pressure, which can sometimes cause edema, they should inform their healthcare provider.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An elderly client with heart failure arrives at the emergency room due to nausea, vomiting, and anorexia.Based on the client’s signs and symptoms, which piece of data from the medical history is most significant when planning this client’s care?

Correct Answer is D

Explanation

A patient with nasal congestion has been prescribed phenylephrine 10 mg by mouth every 4 hours.What patient condition should the nurse report to the healthcare provider before administering the medication?

Correct Answer is A

Explanation

The nurse is administering sodium polystyrene sulfonate to a client with acute kidney injury (AKI). Which laboratory finding indicates that the medication has been effective?

A patient has received a new prescription for levothyroxine.Which statement made by the patient indicates that the education was effective?

A patient with hepatic encephalopathy is receiving lactulose.Which assessment provides the nurse with the best information to evaluate the patient’s therapeutic response to the drug?

An adult patient at an outpatient clinic has been prescribed the antibiotic tetracycline HCl. What instructions should the nurse include in the patient’s teaching plan?

A patient with chemotherapy-induced nausea has been prescribed metoclopramide. What adverse effect should the nurse report?

The nurse is planning care for a client with major depression who is receiving a new prescription for duloxetine. What information is most important for the nurse to obtain?

After taking orlistat for one week, a female patient tells the home health nurse that she is experiencing increasingly frequent oily stools and gas.What action should the nurse take?