The nurse admits a client with a diagnosis of stage 4 cancer. The client has a prescription to wear a subcutaneous morphine sulfate patch for pain. The client is short of breath and difficult to arouse.
While performing a head-to-toe assessment, the nurse discovers four patches on the client’s body. Which action should the nurse take first?
Remove the morphine patches.
Monitor blood pressure.
Apply oxygen face mask.
Administer a narcotic reversal drug.
The Correct Answer is A
The client’s symptoms of being short of breath and difficult to arouse may indicate an overdose of morphine. The nurse should immediately remove the patches to prevent further absorption of the drug. After removing the patches, the nurse should continue to assess the client’s condition and take further actions as needed, such as administering a narcotic reversal drug or providing oxygen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Open-angle glaucoma is a chronic eye condition that can cause irreversible damage to the optic nerve, leading to vision loss or blindness. The primary goal of treatment is to lower and control the intraocular pressure (IOP) to prevent further damage. Eye drops are often prescribed to reduce the IOP and are typically used for long-term control of normal eye pressure, even if the pressure has been reduced to a safe level.
Options a, c, and d are incorrect because they do not reflect the long-term management of open-angle glaucoma.
While reducing excess pressure may be a goal of treatment, it is not a guarantee that the eye drops will be discontinued once the pressure is normalized.
Likewise, restoring a smaller angle or managing pain and swelling may be secondary goals but are not the primary purpose of using eye drops in open-angle glaucoma
Correct Answer is C
Explanation
Diabetes insipidus is a condition in which the kidneys are unable to conserve water, leading to excessive thirst and urination. It is treated with antidiuretic hormone (ADH), which helps the kidneys retain water and reduce urine output. When caring for a client with diabetes insipidus who is receiving ADH intranasally, it is important for the nurse to monitor the client’s serum osmolality.
Osmolality is a measure of the concentration of particles in a solution and can provide information about the client’s hydration status.
Monitoring serum osmolality can help determine if the ADH therapy is effective in managing the client’s diabetes insipidus.
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