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 D

Explanation

The client is experiencing syncope (fainting) due to a drop in blood pressure to 70/40 mm Hg, which is too low. This suggests that the client's blood pressure medications are reducing their blood pressure too much, resulting in hypotension. The rationale for the nurse's decision to hold the client's scheduled antihypertensive medications is to prevent further hypotension and allow the client's blood pressure to stabilize at a safer level.

Option a is incorrect because diuresis (increased urine output) is not a likely cause of the client's hypotension.

Option b is incorrect because the client's symptoms suggest hypotension due to reduced blood pressure, rather than drug toxicity.

Option c is incorrect because the antagonistic interaction among blood pressure medications would result in reduced eﬀectiveness but would not necessarily cause hypotension.

A. Unusual irritability. B. Diarrhea C. Nausea D. Involuntary movements.

Correct Answer is D

Explanation

Metoclopramide is a medication used to treat nausea and vomiting, including those caused by chemotherapy. However, it has a potential adverse eﬀect of causing extrapyramidal symptoms (EPS), which are involuntary movements of the body, such as muscle spasms, twitching, or restlessness. These symptoms can be distressing for patients and can interfere with their quality of life. EPS can be a sign of tardive dyskinesia, a serious and irreversible neurological disorder.

Therefore, it is essential for the nurse to monitor the client for any signs of EPS and report them immediately to the healthcare provider to prevent further complications. Unusual irritability, diarrhea, and nausea are also potential adverse eﬀects of metoclopramide, but they are not as concerning as EPS.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who receives multiple antihypertensive multiple medications experiences syncope due to a drop in blood pressure to 70/40 mm Hg. Which is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medications?

Correct Answer is D

Explanation

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

Correct Answer is D

Explanation

The nurse is planning to administer the antiulcer GI agent sucralfate to a client with a peptic ulcer disease. Which action should the nurse include in this client’s plan of care?

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?

The nurse is planning care for a patient with major depression who is receiving a new prescription for duloxetine. Which information is most important for the nurse to obtain?

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?

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

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?

Which assessment data indicated to the nurse that a client is having an anaphylactic reaction to a medication?

The nurse assesses a client with intermittent claudication who is receiving pentoxifylline. Which assessment should the nurse perform to determine the eﬀectiveness of the medication?