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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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.

A. A coronary artery bypass procedure was performed in 1995. B. Suﬀered with depression following death of spouse in 1999. C. Digoxin and furosemide daily since 1996. D. A Colonoscopy was performed for routine screening six months ago.

Correct Answer is C

Explanation

Digoxin is a medication commonly used to treat heart failure by strengthening the heart's contractions and slowing down the heart rate. However, it can also cause nausea, vomiting, and loss of appetite, especially when levels in the body are too high. Furosemide is a diuretic medication that helps to remove excess ﬂuid from the body, which is often necessary in heart failure. However, it can also cause electrolyte imbalances, such as low potassium levels, which can contribute to nausea and vomiting.

Therefore, in a client with heart failure who is experiencing these symptoms, it is important to assess their medication regimen, including dosages and serum levels, to ensure that they are not experiencing medication side eﬀects or toxicity.

Adjustments may need to be made to the client's medication regimen to manage symptoms eﬀectively and prevent further complications. Options (a), (b), and (d) do not have as direct a correlation to the current symptoms and would not have the same level of significance when planning care for this client.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When caring for a client with diabetes insipidus who is receiving antidiuretic hormone intranasally, which serum lab test is most important for the nurse to monitor?

Correct Answer is C

Explanation

An elderly client with heart failure comet to the emergency room because of nausea, vomiting, and anorexia. Based on the client’s signs and symptoms, which data from the medical history has the most significance when planning this client’s care?

Correct Answer is C

Explanation

On admission, the healthcare provider describes a broad spectrum of antibiotic, ticarcillin for a client with a gram-negative infection. Before administering the first dose, it is most important for the nurse to implement which prescription?

A client with chemotherapy induced nausea receives a prescription for metoclopramide. Which adverse eﬀect is most important for the nurse to report?

The nurse is caring for a client who is taking diclofenac, an NSAID drug for rheumatoid arthritis. During a clinic visit, the client appears pale and reports increasing fatigue. Which of the client’s serum laboratory values is most important for the nurse to review?

A client with bipolar disorder admitted with severe depression and suicidal ideation receives a prescription for lithium carbonate, which instruction should the nurse provide to the client?

An older adult with iron deficiency anemia is being discharged with a prescription for ferrous sulfate enteric-coated tablets. To promote the best absorption of the medication, which information should the nurse include in the discharge instructions?

A client with psychosis who is receiving an antipsychotic medication is continuously rubbing the back of the neck. Which nursing intervention is best for the nurse to implement?

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

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?