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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
(Correct Choice) Checking pupillary response to light is a critical first step in the assessment of a client with multiple injuries following a motor vehicle crash. Pupillary changes can indicate neurological issues, increased intracranial pressure, or damage to the brainstem. Rapidly assessing pupil size, equality, and reactivity helps identify potential life-threatening conditions.
Choice B rationale:
Checking the client's response to questions about place and time is important but not the highest priority in this scenario. Neurological and physiological stability should be addressed first to ensure the client's overall well-being.
Choice C rationale:
Assessing capillary refill is valuable in assessing peripheral circulation and hydration status. However, it is not the primary concern when dealing with a client who has potentially sustained traumatic injuries, where neurological and intracranial issues need to be ruled out or addressed urgently.
Choice D rationale:
Evaluating chest expansion is relevant for assessing lung function and detecting potential injuries like rib fractures. However, given the context of a trauma client, focusing on neurological assessment takes precedence over respiratory assessment in the immediate term.
Correct Answer is B
Explanation
The correct answer is: d. Protective. Protective precautions are crucial for clients who have had an allogeneic hematopoietic stem-cell transplant due to their severely weakened immune systems.
Choice A reason:
Airborne precautions are used for infections that spread through the air, such as tuberculosis and measles. These infections require special ventilation and respiratory protection, which is not the primary concern for stem-cell transplant patients.
Choice B reason:
Contact precautions are used for infections spread by direct contact, like MRSA or C. difficile. These precautions involve wearing gloves and gowns but do not address the airborne or droplet risks that immunocompromised patients face.
Choice C reason:
Droplet precautions are for infections spread by large respiratory droplets, such as influenza or pertussis. While important, they do not provide the comprehensive protection needed for stem-cell transplant recipients.
Choice D reason:
Protective precautions involve placing the patient in a room with HEPA filtration and limiting visitors to minimize infection risk. This is essential for patients with compromised immune systems, such as those who have undergone allogeneic hematopoietic stem-cell transplants.
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