NCLEX RN ACTUAL EXAM TEST BANK OF REAL
QUESTIONS & ANSWERS NCLEX 2024 | NCLEX Exam
A nurse is caring for a cancer patient receiving subcutaneous morphine sulfate
for pain. Which of the following nursing actions is most important in the care of
this patient?
A. Monitor urine output.
B. Monitor respiratory rate.
C. Monitor heart rate.
D. Monitor temperature. - Answer: B
Morphine sulfate can suppress respiration and respiratory reflexes, such as
cough. Patients should be monitored regularly for these effects to avoid
respiratory compromise. Morphine sulfate does not significantly affect urine
output, heart rate, or body temperature.
A postoperative patient has an epidural infusion of morphine sulfate
(Astramorph). The patient's respiratory rate declines to 8 breaths/min. Which
medication would the nurse anticipate administering?
A) Naloxone (Narcan)
B) Acetylcysteine (Mucomyst)
C) Methylprednisolone (Solu-Medrol)
D) Protamine sulfate - A) Naloxone (Narcan)
Naloxone is a narcotic antagonist that can reverse the effects, both adverse and
therapeutic, of opioid narcotic analgesics.
A patient arrives at the emergency department complaining of back pain. He
reports taking at least 3 acetaminophen tablets every three hours for the past
week without relief. Which of the following symptoms suggests acetaminophen
toxicity?
,A. Tinnitus.
B. Diarrhea.
C. Hypertension.
D. Hepatic damage. - Answer: D
Acetaminophen in even modestly large doses can cause serious liver damage
that may result in death. Immediate evaluation of liver function is indicated with
consideration of N-acetylcysteine administration as an antidote. Tinnitus is
associated with ASPIRIN overdose, not acetaminophen. Diarrhea and
hypertension are not associated with acetaminophen.
The nurse is planning care for a patient receiving morphine sulfate (Duramorph)
by means of a patient-controlled analgesia (PCA) pump. Which intervention may
be required because of a potential adverse effect of this drug?
A) Administer cough suppressant.
B) Insert Foley catheter.
C) Administer antidiarrheal.
D) Monitor liver function tests. - B) Insert Foley catheter.
Morphine can cause urinary hesitancy and urinary retention. If bladder
distention or the inability to void is noted, the prescriber should be notified.
Urinary catheterization may be required. Morphine acts as a cough suppressant
and an antidiarrheal, so neither of those drugs would need to be administered to
counteract an adverse effect of morphine. Liver toxicity is not a common
adverse effect of morphine.
A patient admitted to the hospital with a diagnosis of pneumonia asks the nurse,
"Why am I receiving codeine? I don't have any pain." The nurse's response is
based on the knowledge that codeine also has which effect?
A) Immunostimulant
,B) Antitussive
C) Expectorant
D) Immunosuppressant - B) Antitussive
Codeine provides both analgesic and antitussive therapeutic effects.
A patient takes oxycodone (OxyContin), 40 mg PO twice daily, for the
management of chronic pain. Which intervention should be added to the plan of
care to minimize the gastrointestinal adverse effects?
A) Take an antacid with each dose.
B) Eat foods high in lactobacilli.
C) Take the medication on an empty stomach.
D) Increase fluid and fiber in the diet. - D) Increase fluid and fiber in the diet.
Narcotic analgesics reduce intestinal motility, leading to constipation.
Increasing fluid and fiber in the diet can help manage this adverse effect.
Which agent below is most likely to cause serious respiratory depression as a
potential adverse reaction?
A) Morphine (Duramorph)
B) Pentazocine (Talwin)
C) Hydrocodone (Lortab)
D) Nalmefene (Revex) - A) Morphine (Duramorph)
Morphine is a strong opioid agonist and as such has the highest likelihood of
respiratory depression. Pentazocine, a partial agonist, and hydrocodone, a
moderate to strong agonist, may cause respiratory depression but not as often
and serious as morphine. Nalmefene is an opioid antagonist and would be used
to reverse respiratory depression with opioids.
, The nurse is working on a postoperative unit where pain management is part of
routine care. Which statement below is the most helpful in guiding clinical
practice in this setting?
A) At least 30% of the U.S. population is prone to drug addiction and abuse.
B) The development of opioid dependence is rare when opioids are used for
acute pain.
C) Morphine is a common drug of abuse in the general population.
D) The use of PRN (as needed) dosing provides the most consistent pain relief
without risk of addiction. - B) The development of opioid dependence is rare
when opioids are used for acute pain.
A nurse administers naloxone (Narcan) to a postoperative patient experiencing
respiratory sedation. What undesirable effect would the nurse anticipate after
giving this medication?
A) Drowsiness
B) Tics and tremors
C) Increased pain
D) Nausea and vomiting - C) Increased pain
Naloxone is a medication that reverses the effects of narcotics. Although the
patient's respiratory status will improve after the administration of naloxone,
pain will be more acute.
The client informs the nurse that he has experienced pain in the lower
extremities for the past eight months. The nurse recognizes that this pain is
classified as:
a.) Moderate.
QUESTIONS & ANSWERS NCLEX 2024 | NCLEX Exam
A nurse is caring for a cancer patient receiving subcutaneous morphine sulfate
for pain. Which of the following nursing actions is most important in the care of
this patient?
A. Monitor urine output.
B. Monitor respiratory rate.
C. Monitor heart rate.
D. Monitor temperature. - Answer: B
Morphine sulfate can suppress respiration and respiratory reflexes, such as
cough. Patients should be monitored regularly for these effects to avoid
respiratory compromise. Morphine sulfate does not significantly affect urine
output, heart rate, or body temperature.
A postoperative patient has an epidural infusion of morphine sulfate
(Astramorph). The patient's respiratory rate declines to 8 breaths/min. Which
medication would the nurse anticipate administering?
A) Naloxone (Narcan)
B) Acetylcysteine (Mucomyst)
C) Methylprednisolone (Solu-Medrol)
D) Protamine sulfate - A) Naloxone (Narcan)
Naloxone is a narcotic antagonist that can reverse the effects, both adverse and
therapeutic, of opioid narcotic analgesics.
A patient arrives at the emergency department complaining of back pain. He
reports taking at least 3 acetaminophen tablets every three hours for the past
week without relief. Which of the following symptoms suggests acetaminophen
toxicity?
,A. Tinnitus.
B. Diarrhea.
C. Hypertension.
D. Hepatic damage. - Answer: D
Acetaminophen in even modestly large doses can cause serious liver damage
that may result in death. Immediate evaluation of liver function is indicated with
consideration of N-acetylcysteine administration as an antidote. Tinnitus is
associated with ASPIRIN overdose, not acetaminophen. Diarrhea and
hypertension are not associated with acetaminophen.
The nurse is planning care for a patient receiving morphine sulfate (Duramorph)
by means of a patient-controlled analgesia (PCA) pump. Which intervention may
be required because of a potential adverse effect of this drug?
A) Administer cough suppressant.
B) Insert Foley catheter.
C) Administer antidiarrheal.
D) Monitor liver function tests. - B) Insert Foley catheter.
Morphine can cause urinary hesitancy and urinary retention. If bladder
distention or the inability to void is noted, the prescriber should be notified.
Urinary catheterization may be required. Morphine acts as a cough suppressant
and an antidiarrheal, so neither of those drugs would need to be administered to
counteract an adverse effect of morphine. Liver toxicity is not a common
adverse effect of morphine.
A patient admitted to the hospital with a diagnosis of pneumonia asks the nurse,
"Why am I receiving codeine? I don't have any pain." The nurse's response is
based on the knowledge that codeine also has which effect?
A) Immunostimulant
,B) Antitussive
C) Expectorant
D) Immunosuppressant - B) Antitussive
Codeine provides both analgesic and antitussive therapeutic effects.
A patient takes oxycodone (OxyContin), 40 mg PO twice daily, for the
management of chronic pain. Which intervention should be added to the plan of
care to minimize the gastrointestinal adverse effects?
A) Take an antacid with each dose.
B) Eat foods high in lactobacilli.
C) Take the medication on an empty stomach.
D) Increase fluid and fiber in the diet. - D) Increase fluid and fiber in the diet.
Narcotic analgesics reduce intestinal motility, leading to constipation.
Increasing fluid and fiber in the diet can help manage this adverse effect.
Which agent below is most likely to cause serious respiratory depression as a
potential adverse reaction?
A) Morphine (Duramorph)
B) Pentazocine (Talwin)
C) Hydrocodone (Lortab)
D) Nalmefene (Revex) - A) Morphine (Duramorph)
Morphine is a strong opioid agonist and as such has the highest likelihood of
respiratory depression. Pentazocine, a partial agonist, and hydrocodone, a
moderate to strong agonist, may cause respiratory depression but not as often
and serious as morphine. Nalmefene is an opioid antagonist and would be used
to reverse respiratory depression with opioids.
, The nurse is working on a postoperative unit where pain management is part of
routine care. Which statement below is the most helpful in guiding clinical
practice in this setting?
A) At least 30% of the U.S. population is prone to drug addiction and abuse.
B) The development of opioid dependence is rare when opioids are used for
acute pain.
C) Morphine is a common drug of abuse in the general population.
D) The use of PRN (as needed) dosing provides the most consistent pain relief
without risk of addiction. - B) The development of opioid dependence is rare
when opioids are used for acute pain.
A nurse administers naloxone (Narcan) to a postoperative patient experiencing
respiratory sedation. What undesirable effect would the nurse anticipate after
giving this medication?
A) Drowsiness
B) Tics and tremors
C) Increased pain
D) Nausea and vomiting - C) Increased pain
Naloxone is a medication that reverses the effects of narcotics. Although the
patient's respiratory status will improve after the administration of naloxone,
pain will be more acute.
The client informs the nurse that he has experienced pain in the lower
extremities for the past eight months. The nurse recognizes that this pain is
classified as:
a.) Moderate.
