The nurse is caring for a client who is receiving prescribed fentanyl.

Health Care of the Older Adult NCLEX

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Question 1 of 5.

The nurse is caring for a client who is receiving prescribed fentanyl. Which of the following findings would indicate the client is having a side effect? Select all that apply.

A. Nausea and vomiting

B. Constipation

C. Pruritus

D. Urinary retention

E. Nystagmus

Explanation: Fentanyl, an opioid, commonly causes nausea, constipation, pruritus, and urinary retention. Nystagmus is not a typical side effect.

Question 2 of 5.

The physician orders continuous I.V. nitroglycerin infusion for the client with myocardial infarction. Essential nursing actions include which of the following?

A. Obtaining an infusion pump for the medication.

B. Monitoring blood pressure every 4 hours.

C. Monitoring urine output hourly.

D. Obtaining serum potassium levels daily.

Explanation: An infusion pump ensures accurate delivery of nitroglycerin, which requires precise titration. BP monitoring should be more frequent (e.g., every 15-30 minutes), and urine output and potassium levels are not primary concerns.

Question 3 of 5.

A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client is presently complaining of indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/minute per nasal cannula. The nurse's next action would be to:

A. Call for the physician.

B. Start an I.V. line.

C. Obtain a portable chest radiograph.

D. Draw blood for laboratory studies.

Explanation: Indigestion in a client with cardiac risk factors may indicate an MI. Calling the physician promptly ensures rapid evaluation and intervention, such as ECG or medications.

Question 4 of 5.

Captopril (Capoten), furosemide (Lasix), and metoprolol (Toprol XL) are ordered for a client with systolic heart failure. The client's blood pressure is 136/82 and the heart rate is 65. Prior to medication administration at 9 a.m., the nurse reviews the following lab tests (see chart). Which of the following should the nurse do first?

A. Administer the medications.

B. Call the physician.

C. Withhold the captopril.

D. Question the metoprolol dose.

Explanation: The potassium level of 6.8 mEq/L indicates hyperkalemia, a risk with captopril (an ACE inhibitor). Calling the physician is the priority to address this critical lab value.

Question 5 of 5.

A client has returned to the medical-surgical unit after a cardiac catheterization. Which is the most important initial postprocedure nursing assessment for this client?

A. Monitor the laboratory values.

B. Observe neurologic function every 15 minutes.

C. Observe the puncture site for swelling and bleeding.

D. Monitor skin warmth and turgor.

Explanation: Observing the puncture site for swelling and bleeding is critical post-catheterization to detect complications like hematoma or hemorrhage.

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