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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Oxymorphone is not an NSAID (Non-Steroidal Anti-Inflammatory Drug). It is an opioid analgesic, which is used for more severe pain relief. It is not suitable for managing swelling and pain caused by an injury.
Choice B rationale:
Ibuprofen is an NSAID and is an appropriate choice for managing pain and swelling associated with injuries like the patient's knee injury. NSAIDs work by reducing inflammation, which can help alleviate pain and discomfort in such cases.
Choice C rationale:
Acetaminophen is not an NSAID. It is classified as an analgesic and antipyretic, and while it can help with pain relief, it may not be as effective in reducing inflammation, which is essential in cases of swelling due to an injury.
Choice D rationale:
Aspirin is an NSAID, but it is not the best choice for this patient. Aspirin is known to have a higher risk of gastrointestinal side effects, and there are other NSAIDs like ibuprofen that are generally preferred for pain management and inflammation without the same level of side effects.
Correct Answer is C
Explanation
Choice A rationale:
Taking a warm bath before trying to go back to sleep is a relaxation technique that may help with sleep but does not address the underlying causes of insomnia. It is more of a short-term coping strategy rather than a method for locating the reasons for the insomnia.
Choice B rationale:
Reviewing times in her life when she had no insomnia is not a practical approach to addressing the current issue of insomnia. It does not help in identifying the specific factors or triggers contributing to the patient's current sleep problems.
Choice C rationale:
Keeping a diary related to sleep and problems encountered is a practical and effective approach to identify the factors contributing to the patient's insomnia. This diary can help track patterns, such as bedtime routines, diet, stressors, and other variables that may be linked to the sleep problem. Identifying these factors can aid in developing a plan to address the specific causes of the insomnia.
Choice D rationale:
Discussing the problem with her friends may provide emotional support but is unlikely to help identify the root causes of the insomnia. Friends may offer advice or share their experiences, but a structured approach like keeping a sleep diary is more likely to yield valuable information.
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