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A nurse is caring for a client diagnosed with stage 4 cancer who has a prescription for a subcutaneous morphine sulfate patch for pain. The client is short of breath and difficult to arouse. During a head-to-toe assessment, the nurse finds four patches on the client’s body. What should be the nurse’s first action?
- A. Administer a narcotic reversal drug.
- B. Apply an oxygen face mask.
- C. Remove the morphine patches.
- D. Monitor the client’s blood pressure.
Correct Answer: C
Rationale: Four morphine patches suggest overdose, causing respiratory depression and sedation. Removing the patches (C) stops further absorption. Naloxone (A) or oxygen (B) may follow, but removal is first. Blood pressure monitoring (D) is secondary.
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The nurse administers naloxone to a patient with opioid-induced respiratory depression. An hour later, the nurse finds the patient has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unresponsive. What action should the nurse take?
- A. Administer a second dose of naloxone.
- B. Prepare to assist with chest tube insertion.
- C. Determine Glasgow Coma Scale score.
- D. Initiate cardiopulmonary resuscitation (CPR).
Correct Answer: D
Rationale: Severe respiratory depression (4 breaths/min), hypoxia (75% SpO₂), and unresponsiveness require immediate CPR (D) to restore circulation/oxygenation. A second naloxone dose (A) may be needed but is secondary. Chest tubes (B) are irrelevant. Glasgow scoring (C) delays critical intervention.
A patient with nasal congestion has been prescribed phenylephrine 10 mg by mouth every 4 hours. What patient condition should the nurse report to the healthcare provider before administering the medication?
- A. Hypertension.
- B. Bronchitis.
- C. Diarrhea.
- D. Edema.
Correct Answer: A
Rationale: Phenylephrine, a decongestant, can raise blood pressure, making hypertension (A) a contraindication requiring provider consultation. Bronchitis (B), diarrhea (C), and edema (D) are not directly affected by phenylephrine.
A female patient with multiple sclerosis reports less fatigue and improved memory since she started using the herbal supplement, ginkgo biloba. What is the most important information for the nurse to include in the teaching plan for this patient?
- A. Nausea and diarrhea can occur when using this supplement.
- B. Ginkgo biloba use should be limited and not taken during pregnancy.
- C. Aspirin and non-steroidal anti-inflammatory drugs interact with ginkgo.
- D. Anxiety and headaches increase with the use of ginkgo biloba.
Correct Answer: C
Rationale: This question is identical to Question 39. Ginkgo biloba’s interaction with aspirin/NSAIDs (C) increases bleeding risk, a critical teaching point. Other side effects (A, D) and pregnancy limits (B) are less urgent. Note: Duplicate question; consider removing.
The nurse is preparing to administer the anti-ulcer gastrointestinal agent sucralfate to a patient with peptic ulcer disease. What should be included in this patient’s care plan?
- A. Administer sucralfate once daily, preferably at bedtime.
- B. Give sucralfate on an empty stomach.
- C. Monitor for a secondary Candida infection.
- D. Monitor for electrolyte imbalances.
Correct Answer: B
Rationale: Sucralfate forms a protective barrier over ulcers and should be given on an empty stomach (B), 1 hour before meals or at bedtime, for optimal efficacy. Once-daily dosing (A) is incorrect; it’s typically 4 times daily. Candida infection (C) and electrolyte imbalances (D) are not associated with sucralfate.
An elderly client with heart failure arrives at the emergency room due to nausea, vomiting, and anorexia. Based on the client’s signs and symptoms, which piece of data from the medical history is most significant when planning this client’s care?
- A. The client underwent a coronary artery bypass procedure in 1995.
- B. The client had a colonoscopy performed for routine screening six months ago.
- C. The client suffered from depression following the death of their spouse in 1999.
- D. The client has been taking digoxin and furosemide daily since 1996.
Correct Answer: D
Rationale: Digoxin and furosemide (D) can cause nausea, vomiting, and anorexia due to toxicity (digoxin) or electrolyte imbalances (furosemide), critical for heart failure management. Past bypass (A), colonoscopy (B), and depression (C) are less relevant to current symptoms.