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 A
Explanation
Insulin glargine is a long-acting insulin that is given once daily at the same time every day via subcutaneous injection. Therefore, it is essential to teach the client self-injection skills for daily subcutaneous administration to ensure proper administration of insulin.
Option b is incorrect because insulin glargine is typically given at the same dose every day, not based on before meal blood sugar readings.
Option c is incorrect because insulin glargine is not used for the treatment of severe hypoglycemia, and it should not be administered by someone who is not trained to do so.
Option d is incorrect because ketoacidosis is a serious complication of diabetes mellitus that requires urgent medical atention, and increasing medication dosage is not appropriate for this condition.
Correct Answer is A
Explanation
Gentamicin sulfate is an aminoglycoside antibiotic that can cause ototoxicity, which is damage to the inner ear leading to hearing loss or balance problems. Therefore, a decrease in hearing is an indication that the client may be experiencing an adverse effect of gentamicin.
Option b, decreased blood urea nitrogen, is not an adverse effect of gentamicin, but it may indicate improvement in kidney function, which can be a positive outcome of treatment.
Option c, a white blood cell count of 6,000/mm3 (6x109/L), is within the normal range and is not necessarily an adverse effect of gentamicin.
Option d, photophobia, is not a common adverse effect of gentamicin and may indicate a different condition or medication effect.
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