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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Free Nursing Study Resources

Correct Answer is C

Explanation

Continuous rubbing of the back of the neck can be a side eﬀect of antipsychotic medication, known as acute dystonia. Benztropine is an anticholinergic medication that can eﬀectively treat acute dystonia. Therefore, the nurse should give a PRN prescription for benztropine to relieve the client's discomfort. Options a, b, and d do not address the underlying issue of acute dystonia and are not the best interventions for this particular situation.

A. Administer sucralfate once a day, preferably at bedtime. B. Asses for secondary candida infection. C. Monitor for electrolyte imbalance. D. Give sucralfate on an empty stomach.

Correct Answer is D

Explanation

Sucralfate is a medication used to treat and prevent the return of duodenal ulcers. It is important to take sucralfate on an empty stomach, either 1 hour before meals or 2 hours after meals. This allows the medication to work eﬀectively by sticking to damaged ulcer tissue and protecting against acid and enzymes so healing can occur.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with psychosis who is receiving an antipsychotic medication is continuously rubbing the back of the neck. Which nursing intervention is best for the nurse to implement?

Correct Answer is C

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?

Correct Answer is D

Explanation

When caring for a client with diabetes insipidus who is receiving antidiuretic hormone intranasally, which serum lab test is most important for the nurse to monitor?

A client is scheduled for a spiral computed topography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client’s history requires follow-up by the nurse?

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?

Prior to administering the evening dose of carbamazepine, the nurse noted that the client’s morning carbamazepine level was 8.4 mg/L. Which action should the nurse take?

The nurse is preparing a discharge teaching plan for a clientwho is taking ciproﬂoxacin hydrochloride tablets which were prescribed because of a suspected anthrax exposure. Which instructions should be included in the teaching plan? (Select all that apply.)

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?

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 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?