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
A. Administers onto the fleshy outer thigh: This is the recommended site for epinephrine auto-injection because it allows for quick absorption into the bloodstream. The outer thigh is a large muscle area, which helps in the rapid distribution of the medication.
B. Inserts the injection pen through clothing: It is generally acceptable to inject epinephrine through clothing in an emergency situation. This practice ensures that there is no delay in administering the life-saving medication, which is crucial during an anaphylactic reaction.
C. Cleanses the injection pen for re-use: Epinephrine auto-injectors are designed for single use only. Reusing the pen can lead to contamination and reduced effectiveness of the medication. It is important to dispose of the used injector properly and obtain a new one for future use.
D. Holds the pen in place after injection: Holding the pen in place for a few seconds after injection ensures that the full dose of medication is delivered. This practice helps in maximizing the effectiveness of the treatment during an anaphylactic emergency.
Correct Answer is B
Explanation
Sumatriptan succinate is a medication used to treat migraine headaches by narrowing blood vessels in the brain. It is important to determine if the client has a history of coronary artery disease before administering the initial dose because the medication can also cause narrowing of the coronary arteries and potentially lead to a heart attack or other cardiac events.
Type 2 diabetes mellitus (a), seasonal allergic rhinitis (c), and irritable bowel syndrome (d) are not directly related to the use of sumatriptan succinate. However, it is still important to consider the client's medical history and overall health status when prescribing or administering any medication.
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