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

Tamsulosin is an alpha-1 adrenergic receptor blocker that is commonly used to treat benign prostatic hyperplasia (BPH). One of the potential adverse reactions of tamsulosin is hypotension, which can be manifested as dizziness, lightheadedness, and fainting. Therefore, monitoring blood pressure is a crucial intervention for clients receiving tamsulosin.

Assessing urine output (option a) and performing a bladder scan (option b) may be appropriate interventions for clients with urinary retention or other urinary tract issues, but they are not specific to monitoring adverse reactions to tamsulosin.

Obtaining daily weights (option d) may be useful for monitoring ﬂuid balance in some clients, but it is not directly related to adverse reactions to tamsulosin.

A. Reports on increased energy levels and decreased fatigue. B. Takes concurrent iron therapy without adverse eﬀects. C. The hemoglobin level increased to 12 grams/dL (120mmol/L). D. Food diary shows increased consumption of iron rich foods.

Correct Answer is C

Explanation

Epoetin alfa is a medication that stimulates the production of red blood cells and is commonly used to treat anemia in patients with chronic kidney disease. Hemoglobin level is the most important parameter to monitor the eﬀectiveness of epoetin alfa therapy. An increase in hemoglobin level indicates an improvement in the patient's anemia and suggests that the medication is eﬀective.

While options a, b, and d are also important considerations in the management of anemia, they do not provide a definitive indication of the eﬀectiveness of epoetin alfa therapy. Reports of increased energy levels and decreased fatigue can be subjective and inﬂuenced by many factors. Taking concurrent iron therapy without adverse eﬀects is important to support the production of red blood cells but does not confirm the eﬀectiveness of epoetin alfa. Increased consumption of iron-rich foods can be helpful in managing anemia, but it does not provide a direct indication of the eﬀectiveness of epoetin alfa therapy.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with benign prostatic receives a new prescription of tamsulosin. Which intervention should the nurse use to monitor an adverse reaction?

Correct Answer is C

Explanation

A client with anemia secondary to chronic kidney disease started a prescription for epoetin alfa two months ago. Which client finding best indicates that the medication is eﬀective?

Correct Answer is C

Explanation

An older adult client with restless legs syndrome begins taking melatonin at bedtime. When evaluating the eﬀectiveness of the herb which client assessment should the nurse complete?

A client with hepatic encephalopathy is receiving lactulose. Which assessment provides the nurse with the nest information to evaluate the client’s therapeutic response to the drug?

A female client starts a new prescription, oxybutynin, for symptoms of an overactive bladder. The client tells the nurse that she is training to run in a marathon. Which instruction should the nurse emphasize?

The nurse administers risedronate to a client with osteoporosis at 07:00. The client asks for a glass of milk to drink with the medication. Which action should the nurse take?

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?

Which nursing action had the highest priority when administering a dose of codeine with acetaminophen to a client?

A client with muscle spasticity receives a prescription for baclofen. Which information provided by the client requires additional instruction by the nurse?

Before administering initial dose of sumatriptan succinate to a client with a migraine headache, it is most to determine if the client’s history includes which problem?