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

Intermittent claudication is a condition in which there is pain in the legs due to reduced blood ﬂow. Pentoxifylline is a medication that can improve blood ﬂow by reducing the viscosity of the blood. Therefore, to determine the eﬀectiveness of the medication in managing intermittent claudication, the nurse should monitor the client's pain level using a numeric pain scale. This will help to assess if the medication provides pain relief and improving the client's ability to walk without discomfort.

Options a, b, and c are not relevant to the assessment of the eﬀectiveness of pentoxifylline in managing intermittent claudication.

A. Review the client’s culture and sensitivity reports. B. Inform the client that the medication has been successful. C. Implement neutropenic precautions. D. Assess the clients’ vital signs.

Correct Answer is B

Explanation

Filgrastim is a medication used to increase the production of white blood cells. An increase in the client’s white blood cell count from 2,500/mm3 to 5,000/mm3 after receiving five doses of filgrastim indicates that the medication has been eﬀective in increasing the client’s white blood cell count. The nurse should inform the client of this positive outcome.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

After receiving five doses of filgrastim, the nurse notes that the clients white blood cell count has increased from 2,500/mm3 to 5,000/mm3. Which action would the nurse take?

Correct Answer is B

Explanation

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?

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

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 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 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?

Two months after taking nitrofurantoin for a bacterial infection, a client reports the onset of severe, watery diarrhea to the home care nurse. How should the nurse respond?

The nurse is providing instructions about a client’s new medication. How should the nurse explain the purpose of probenecid, a uricosuric drug?