A nurse caring for a patient with a Fentanyl patch assesses that the patient is abnormally sleepy, is slurring words, and is unsteady when ambulating.
The nurse should:.

remove the patch and wipe off the skin.

apply ice to the skin around the patch.

elevate the head of the bed 45 degrees and offer coffee or cola drink.

put up the side rails on the bed.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

If a patient with a Fentanyl patch is experiencing symptoms like abnormal sleepiness, slurred speech, and unsteadiness when ambulating, it could indicate an overdose or adverse reaction to the Fentanyl. In such cases, the patch should be removed immediately to stop the further absorption of the drug. Wiping off the skin can also help remove any residual medication. This is the correct choice as it addresses the issue at its source.

Choice B rationale:

Applying ice to the skin around the Fentanyl patch is not the appropriate action in this situation. Ice will not counteract the effects of a Fentanyl overdose or adverse reaction. The priority is to remove the patch and seek medical attention.

Choice C rationale:

Elevating the head of the bed and offering coffee or cola may be useful in combating some forms of sleepiness but would not be effective for someone experiencing an overdose or adverse reaction to Fentanyl. This choice does not address the problem's root cause and is not the appropriate action to take.

Choice D rationale:

Putting up the side rails on the bed does not address the issue of Fentanyl patch overdose or adverse reactions. This choice is not relevant to the situation and should not be chosen.

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

Explanation

Choice A rationale:
Using a pain scale from 0 to 10 is a crucial principle in managing a client's postoperative pain. It allows for a standardized assessment of pain severity and helps healthcare providers determine the effectiveness of pain management interventions.
Choice B rationale:
Considering the client's individual expression of pain is essential in providing personalized care. People experience and express pain differently, so tailoring the approach to each client's unique needs is vital for effective pain management.
Choice C rationale:
Expecting the client to express pain both verbally and nonverbally is another important principle in pain management. Some clients may not be able to communicate verbally, so nurses should be attentive to nonverbal cues such as grimacing, restlessness, or changes in vital signs to assess pain.
Choice D rationale:
Administering opioids with caution is a general principle in pain management, but the statement that they will eventually lead to addiction is an oversimplification. While there is a risk of opioid addiction, it is not an absolute certainty, and the benefits of pain relief often outweigh the risks. Therefore, this statement is not entirely accurate.
Choice E rationale:
Administering analgesics for fast-acting pain relief is a valid principle, especially in the postoperative period when the client may be experiencing acute pain. Fast-acting analgesics help alleviate immediate discomfort.

A. Decreased respirations, rapid heart rate. B. Rapid respirations, rapid heart rate. C. Rapid respirations, slow heart rate. D. Decreased respirations, slow heart rate.

Correct Answer is B

Explanation

Choice A rationale:

Decreased respirations and a rapid heart rate are not indicative of stage 3 of non-rapid eye movement (NREM) sleep. In stage 3, respirations are typically slow and regular, and the heart rate is slower than during wakefulness.

Choice B rationale:

Rapid respirations and a rapid heart rate are indicative of stage 3 of NREM sleep. During this stage, respiration and heart rate are more irregular compared to the earlier stages of sleep. This stage is characterized by increased physiological arousal compared to stages 1 and 2.

Choice C rationale:

Rapid respirations and a slow heart rate do not represent stage 3 of NREM sleep. In this stage, respiration tends to be rapid, and the heart rate, while slower than during wakefulness, is not slow.

Choice D rationale:

Decreased respirations and a slow heart rate are not consistent with stage 3 of NREM sleep. This stage is associated with more active and variable physiological processes, including rapid respirations and a relatively higher heart rate compared to later sleep stages.

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A nurse caring for a patient with a Fentanyl patch assesses that the patient is abnormally sleepy, is slurring words, and is unsteady when ambulating.The nurse should:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative. When helping to manage the client's pain, which of the following principles should the nurse apply? (Select all that apply.).

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

Explanation

A nurse is assessing the status of a patient who is sleeping.Which assessment data indicate that the patient is most likely in stage 3 of non-rapid eye movement (NREM) sleep?

Correct Answer is B

Explanation

A nurse is assisting with teaching a client who has obstructive sleep apnea (OSA) about continuous positive airway pressure (CPAP). Which of the following instructions should the nurse include?

The nurse performing a focused assessment on pain will assess: (Select all that apply.).

A nurse is preparing a patient for home care following cancer treatment. He is discussing the use of the fentanyl patch. Which of the following would be the most important instruction regarding safety?

A patient experiencing pain states that guided imagery has made the pain more manageable in the past.To assist this patient, the nurse should:.

Signs of fentanyl patch overdose are:.

A nurse caring for a patient with a Fentanyl patch assesses that the patient is abnormally sleepy, is slurring words, and is unsteady when ambulating.The nurse should:.

The patient with a recent abdominal incision has an abdominal binder applied. The nurse explains that this appliance helps reduce pain by:.

A nurse explains that endorphins are capable of reducing pain:

A nurse caring for a patient with a Fentanyl patch assesses that the patient is abnormally sleepy, is slurring words, and is unsteady when ambulating.
The nurse should:.