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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Atorvastatin is a medication used to lower cholesterol levels in the blood. One of its side eﬀects is muscle damage, which can result in an increase in serum creatine phosphokinase (CK) levels. Creatine phosphokinase is an enzyme found in muscles, and when muscles are damaged, CK is released into the bloodstream. Therefore, an increased serum CK level indicates muscle damage, and the nurse should assess the client for muscle tenderness or weakness, which are symptoms of this side eﬀect. Nausea and vomiting, excessive bruising, and peripheral edema are not typically associated with atorvastatin use.

A. Assess anxiety level. B. Observe for peripheral edema. C. Determine sleep patterns. D. Palpate pedal pulse volume.

Correct Answer is C

Explanation

Restless legs syndrome is a condition that causes an uncomfortable sensation in the legs and an uncontrollable urge to move them. Melatonin is a natural hormone that helps regulate the sleep-wake cycle and can be used as a sleep aid. Therefore, when evaluating the eﬀectiveness of melatonin in an older adult client with restless legs syndrome, the nurse should assess the client's sleep patterns to determine if the herb is improving their ability to fall and stay asleep.

Assessing anxiety level (a) may be useful in other contexts, but it is not directly relevant to evaluating the eﬀectiveness of melatonin for restless legs syndrome. Observing for peripheral edema (b) and palpating pedal pulse volume (d) are important assessments in clients with peripheral vascular disease or other circulatory disorders, but they are not directly related to restless legs syndrome or the use of melatonin.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client taking atorvastatin becomes an increased serum creatine phosphokinase (CK) level. The nurse should assess the client for the onset of which problem?

Correct Answer is D

Explanation

An older adult client with restless legs syndrome begins taking melatonin at bedtime. When evaluating the eﬀectiveness of the herb which client assessment should the nurse complete?

Correct Answer is C

Explanation

The nurse assesses a client with intermittent claudication who is receiving pentoxifylline. Which assessment should the nurse perform to determine the eﬀectiveness of the medication?

A female client starts a new prescription, oxybutynin, for symptoms of an overactive bladder. The client tells the nurse that she is training to run in a marathon. Which instruction should the nurse emphasize?

A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?

Which nursing action had the highest priority when administering a dose of codeine with acetaminophen to a client?

The nurse is preparing a client with Chronic Obstructive Pulmonary Disease (COPD) and a chronic productive cough for discharged home. Which prescribed medication should the nurse review with the client to manage this symptom?

A client with muscle spasticity receives a prescription for baclofen. Which information provided by the client requires additional instruction by the nurse?

A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in this patient’s plan of care?

Which assessment data indicated to the nurse that a client is having an anaphylactic reaction to a medication?