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
Levothyroxine is a thyroid hormone replacement medication used to treat hypothyroidism. To ensure proper absorption and effectiveness of the medication, it should be taken on an empty stomach, preferably in the morning, and at least 30 minutes before eating. Therefore, when the client indicates that they understand the need to take the medication on an empty stomach, it indicates that the education was effective.
Option b, "Avoid the use of iron supplements," is also important education for clients taking levothyroxine because iron supplements can interfere with the absorption of the medication. However, it is not the best indicator of effective education because the question asks for the statement that indicates education was effective, and option a is a more direct and specific response to the medication.
Option c, "Administer levothyroxine at bedtime," is not accurate information because the medication should be taken in the morning on an empty stomach.
Option d, "Consume foods that are high in iodine," is not recommended for clients taking levothyroxine because high amounts of iodine can interfere with thyroid function. Therefore, this statement indicates a need for further education.
Correct Answer is A
Explanation
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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