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

A total calcium level of 14 mg/dL (3.5 mmol/L) is higher than the normal range of 2.2 to 2.6 millimoles per liter (mmol/L)1. Calcitriol and calcium carbonate are both medications used to increase calcium levels in the blood2. Since the client’s calcium level is already high, it would be important for the nurse to hold both medications and contact the healthcare provider for further instructions.

A. Review the client’s culture and sensitivity reports. B. Inform the client that the medication has been successful. C. Implement neutropenic precautions. D. Assess the clients’ vital signs.

Correct Answer is B

Explanation

Filgrastim is a medication used to increase the production of white blood cells. An increase in the client’s white blood cell count from 2,500/mm3 to 5,000/mm3 after receiving five doses of filgrastim indicates that the medication has been eﬀective in increasing the client’s white blood cell count. The nurse should inform the client of this positive outcome.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Prior to administering oral doses of calcitriol and calcium carbonate to a client with hypoparathyroidism, the nurse notes that the total level of calcium is 14 mg/dL (3.5 mmol/L). Which action should the nurse implement?

Correct Answer is D

Explanation

After receiving five doses of filgrastim, the nurse notes that the clients white blood cell count has increased from 2,500/mm3 to 5,000/mm3. Which action would the nurse take?

Correct Answer is B

Explanation

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

A client receives a new prescription for levothyroxine. Which statement made by client indicates to the nurse that the education was eﬀective?

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

The home health nurse observes a client self-administering an epinephrine injection using an auto-injector pen. Which client action requires intervention by the nurse?

The nurse is preparing a discharge teaching plan for a clientwho is taking ciproﬂoxacin hydrochloride tablets which were prescribed because of a suspected anthrax exposure. Which instructions should be included in the teaching plan? (Select all that apply.)

A client is scheduled for a spiral computed topography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client’s history requires follow-up by the nurse?

The nurse is providing instructions about a client’s new medication. How should the nurse explain the purpose of probenecid, a uricosuric drug?

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?