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 C
Explanation
Baclofen is a muscle relaxant medication used to treat muscle spasticity, which is a condition that causes muscles to become stiff and rigid. It works by reducing the activity of nerves in the brain and spinal cord that cause muscle spasms.
Option a, using stool softener as needed, is appropriate because baclofen can cause constipation as a side effect.
Option b, avoiding ingestion of alcohol, is also appropriate because alcohol can increase the sedative effects of baclofen and cause drowsiness or dizziness.
Option d, taking medication with meals, is recommended because it can help reduce stomach upset and nausea that may occur as a side effect of the medication.
Option c, discontinuing the medication when spasms cease, is incorrect because muscle spasticity is a chronic condition, and baclofen is used to manage symptoms over a prolonged period. Discontinuing the medication abruptly can cause withdrawal symptoms and exacerbate the spasticity. Therefore, the nurse should educate the client to take the medication as prescribed by the healthcare provider and not discontinue it without medical advice.
Correct Answer is D
Explanation
A carbamazepine level of 8.4 mg/L is within the therapeutic range of 4-12 mg/L. The nurse should administer the evening dose of carbamazepine as prescribed. The nurse should continue to monitor the client’s carbamazepine levels and assess for any side effects of the medication.
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