A Cardiovascular nurse is giving transdermal Fentanyl as per ordered to the patient. What is an important safety measure to take when changing and applying a transdermal patch?

Wash hands for 5 to 10 seconds prior to administering the medication.

Apply the patch over a non-hairy area within the patient's skin.

Leave the previous medication patch in place.

Always ensure that the patient is lying down.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Washing hands for 5 to 10 seconds prior to administering medication is indeed an important safety measure, but it is not specifically related to changing or applying a transdermal patch. Hand hygiene is crucial to prevent the spread of infection, but it doesn't directly address the process of applying a patch.

Choice B rationale:

Applying the patch over a non-hairy area within the patient's skin is the correct answer. This is crucial because hair can interfere with the adhesion of the patch, leading to inadequate drug absorption. The rationale behind this is to ensure that the medication is effectively delivered through the skin into the bloodstream without any barriers such as hair. It's also important to choose a site that is clean, dry, and free from cuts or irritation.

Choice C rationale:

Leaving the previous medication patch in place is not recommended. It's essential to remove the old patch before applying a new one to prevent accumulation of the medication and to ensure accurate dosing. Failing to remove the previous patch could lead to an overdose or altered drug effects.

Choice D rationale:

Ensuring that the patient is lying down is not a specific safety measure for changing or applying a transdermal patch. The patient's position doesn't directly impact the effectiveness of the patch or the safety of the application process.

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Correct Answer is A

Explanation

Choice A rationale:

This statement indicates a need for further teaching. Synthetic clothing and woolen socks can generate static electricity, which poses a risk around oxygen due to its flammable nature. The client should be advised to wear cotton clothing and avoid synthetic fabrics to prevent static-related accidents.

Choice B rationale:

This statement is correct. Oxygen supports combustion, so ensuring visitors don't smoke near the client is crucial. However, it does not indicate a need for further teaching.

Choice C rationale:

This statement is incorrect. The client cannot determine the oxygen flow rate by visual inspection of the flowmeter. The flow rate should be set based on the healthcare provider's instructions, and this information should have been covered in the teaching.

Choice D rationale:

This statement indicates the client understands the potential cognitive effects of oxygen therapy and when to seek medical assistance. It does not necessarily indicate a need for further teaching.

A. Offer a glass of water to the patient. B. Monitor the patient for signs and symptoms of shock. C. Place moist sterile gauze over the site. D. Gently place the organs back. E. Contact the patient's Surgeon.

Correct Answer is ["B","C","E"]

Explanation

Choice A rationale:

Offering a glass of water to the patient is not a priority action when dealing with a surgical incision that eviscerates. This situation requires immediate intervention to prevent complications related to the evisceration.

Choice B rationale:

Monitoring the patient for signs and symptoms of shock is crucial in this scenario. Evisceration, the protrusion of organs from a surgical incision, can lead to significant blood loss, which may result in shock. Signs of shock include hypotension, tachycardia, pallor, diaphoresis, and altered mental status.

Choice C rationale:

Placing moist sterile gauze over the site is appropriate to prevent the exposed organs from drying out and becoming further damaged. It also helps to reduce the risk of infection. Moist sterile gauze helps maintain a sterile environment and prevents the organs from being exposed to contaminants.

Choice D rationale:

Gently placing the organs back into the abdominal cavity is not within the nurse's scope of practice. This action requires surgical intervention by a healthcare provider. The nurse's role is to provide immediate first aid and notify the surgeon.

Choice E rationale:

Contacting the patient's surgeon is essential. Evisceration is a surgical emergency, and the surgeon needs to be informed promptly to make decisions regarding further interventions. The patient may require emergency surgery to address the evisceration and prevent complications.

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A Cardiovascular nurse is giving transdermal Fentanyl as per ordered to the patient. What is an important safety measure to take when changing and applying a transdermal patch?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

Correct Answer is A

Explanation

A nurse on the Medical-Surgical unit is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.).

Correct Answer is ["B","C","E"]

Explanation

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

A nurse is caring for an Islamic client who is recovering from a motor vehicle accident. The patient is observing Ramadan, the ninth lunar month. The nurse understands that a good diet is important for the client's wounds to heal. Which action should the nurse take regarding the client's diet?

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