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 D

Explanation

Choice A rationale:

Some older adults may indeed have concerns about taking pain medication, but this is not a primary reason for their hesitance to express pain. The fear of taking medication is not a universal characteristic of older adults.

Choice B rationale:

While older adults may be reluctant to bother nursing staff, this is not the primary reason for their reluctance to express pain. It is a consideration but not the main factor.

Choice C rationale:

The unawareness of discomfort is not a common reason for older adults to avoid expressing pain. Most older adults are aware of their discomfort but may not express it for other reasons.

Choice D rationale:

Older adults may have been culturally trained not to complain about pain or discomfort. In some cultures, stoicism and not burdening others with one's pain are highly valued. This cultural training can lead older adults to underreport their pain.

Choice E rationale:

Believing pain is a natural consequence of aging is a misconception, but it is not the primary reason why older adults may not express their pain. They may believe this, but cultural and societal factors have a more significant impact.

A. supporting surface and internal tissues. B. adding back support to enhance early ambulation. C. increasing warmth to the incision site. D. keeping sutures and staples in place.

Correct Answer is A

Explanation

The patient with a recent abdominal incision has an abdominal binder applied. The nurse explains that this appliance helps reduce pain by: The correct answer is choice A: supporting surface and internal tissues.

Choice A rationale:
An abdominal binder is primarily used to support surface and internal tissues. It provides gentle compression and support to the abdominal area, which can reduce pain and discomfort. By holding the incision site together and supporting the surrounding tissues, it can minimize movement and strain on the incision, helping to alleviate pain.
Choice B rationale:
While an abdominal binder may indirectly contribute to back support by stabilizing the abdominal area, its primary purpose is to support the surgical site. Enhancing early ambulation is more related to patient mobility and not the primary purpose of the binder.
Choice C rationale:
Abdominal binders do not increase warmth to the incision site. In fact, excessive warmth can lead to sweating and moisture, potentially increasing the risk of infection. The primary purpose is to provide support.
Choice D rationale:
An abdominal binder does not keep sutures and staples in place. The sutures and staples are used to secure the incision, and the binder is placed over them to provide support and compression. However, the binder itself is not responsible for keeping sutures and staples in place. .

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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

The nurse attempts to help an 86-year-old patient describe his pain because the nurse is aware the older adult may not express pain because they:.

Correct Answer is D

Explanation

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

Correct Answer is A

Explanation

A relative complains that an older adult patient takes frequent naps late in the day and awakens frequently during the night and wants to know if this is normal. The nurse explains that an older adult:.

A patient who has difficulty falling asleep at night because of anxiety over family problems asks if he should start taking sedative pills from the pharmacy to sleep better.The best advice to give this patient is that these pills can be used for:.

A natural supplement that can enhance sleep for many people is:.

The nurse recommends that normal sleep and rest patterns can best be acquired by suggesting to the patient that they:.

The nurse appreciates the principal advantage in using patient-controlled analgesia (PCA) is that it:.

The nurse outlines the four phases of nociceptive pain as: (Select all that apply.).

A patient is receiving an ice massage for relief of muscle spasms in the neck.The patient complains that the ice is making the pain worse.Most helpful response from the nurse would be:.

There are several different types of pain.Which type of pain occurs after the loss of a body part from an amputation?

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:.