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:

Bradycardia, a slow heart rate, is not typically associated with acute pain. In response to pain, the body usually experiences increased heart rate (tachycardia) as part of the stress response.

Choice B rationale:

A decreased respiratory rate is not an expected finding in response to acute pain. Acute pain often leads to increased respiratory rate as the body attempts to manage the pain and stress.

Choice C rationale:

Hypoglycemia, a low blood sugar level, is not a typical physiological response to acute pain. Acute pain is more likely to induce a release of stress hormones, such as cortisol and adrenaline, which can lead to increased blood sugar levels.

Choice D rationale:

Hypertension, or elevated blood pressure, is an expected physiological response to acute pain. Pain activates the body's stress response, leading to increased sympathetic nervous system activity, which can cause vasoconstriction and increased blood pressure. This response helps prepare the body to cope with the pain and stress. Monitoring blood pressure in a client reporting acute pain is essential to assess the impact of pain and determine appropriate pain management strategies.

A. True B. False

Correct Answer is A

Explanation

Choice A rationale:

Going to bed hungry or overly full can interfere with sleep. When you're too hungry, your body may be uncomfortable and unable to relax, making it difficult to fall asleep. Conversely, going to bed overly full can lead to discomfort, and indigestion, and may result in disrupted sleep. Therefore, it does not help the patient reach REM (Rapid Eye Movement) sleep faster.

Choice B rationale:

Overeating or going to bed hungry does not aid in reaching REM sleep faster. It is essential for individuals to have a balanced diet and avoid excessive hunger or fullness to promote a healthy sleep pattern. REM sleep is a stage of deep sleep that occurs cyclically throughout the night, and it is influenced by various factors, including individual sleep patterns and circadian rhythms.

Choice C rationale:

REM sleep, a stage of deep sleep, is not influenced by going to bed hungry or overly full. Instead, it is primarily regulated by the body's internal clock and sleep-wake cycles. Factors such as hunger or fullness may affect the quality of sleep but do not contribute to reaching REM sleep faster.

Choice D rationale:

False. Going to bed hungry or overly full does not have a direct impact on the patient's ability to reach REM sleep faster. REM sleep is a natural part of the sleep cycle and is influenced by various factors, such as circadian rhythms, sleep disorders, and medications, but not by the state of hunger or fullness.

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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 collecting data on a client who reports acute pain at a level of 7 on a scale of 0 to 10. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

Going to bed hungry or overly full does not interfere with sleep. It helps the patient reach REM state of sleep faster.

Correct Answer is A

Explanation

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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:.