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 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.

Correct Answer is A
Explanation
Terbinafine HCL is primarily metabolized by the liver, and a history of alcoholism may indicate liver dysfunction or damage, which could affect the metabolism and clearance of the drug. The nurse should assess the client's liver function, including liver enzymes, bilirubin levels, and albumin levels, before administering terbinafine HCL.
While options b, c, and d may be important assessment findings, they are not as crucial as a history of alcoholism when it comes to administering terbinafine HCL.
The thick and yellow toenails (option b) are typical symptoms of a fungal toenail infection, which is the reason for prescribing terbinafine HCL.
The white blood cell count (option c) is within normal range.
Being employed as a construction worker (option d) does not have a direct impact on the use of terbinafine HCL.

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