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:
A patient with a decreased level of consciousness from a stroke may not be able to provide feedback or recognize discomfort or pain, which can increase the risk of burn injury when using a heating pad. This choice increases the risk rather than reducing it.
Choice B rationale:
A patient with neuritis secondary to diabetes has a decreased sensitivity in the affected area due to nerve damage. While this can be a challenging condition, it reduces the patient's ability to perceive heat and pain, making them less likely to realize if the heating pad becomes too hot. As a result, this patient has the least risk for burn injury when using the Aquathermia K pad.
Choice C rationale:
A severely sprained ankle is not related to the risk of burn injury from a heating pad. This choice is not relevant to the assessment of burn injury risk with the Aquathermia K pad.
Choice D rationale:
Impaired peripheral circulation can increase the risk of burn injury from a heating pad. Patients with compromised circulation have a reduced ability to dissipate heat, which can lead to localized overheating and potential burn injury. This choice increases the risk of injury. .
Correct Answer is A
Explanation
Choice A rationale:
Sleep influences memory. During the different stages of sleep, particularly during deep sleep (slow-wave sleep and rapid eye movement sleep), the consolidation of memories occurs. This means that sleep plays a critical role in memory function.
Choice B rationale:
Sleep influences mood. A lack of sleep or disrupted sleep patterns can lead to mood disturbances, including irritability, anxiety, and depression. Adequate sleep is essential for maintaining a stable and positive mood.
Choice C rationale:
Sleep influences cognitive function. Sleep is crucial for cognitive processes such as attention, problem-solving, and decision-making. Sleep deprivation can impair cognitive function, leading to reduced alertness and cognitive performance.
Choice D rationale:
Sleep influences the secretion of various hormones. Sleep plays a significant role in regulating hormones such as growth hormone, cortisol, and melatonin. Disruptions in sleep can lead to imbalances in these hormones, affecting various physiological processes.
Choice E rationale:
Sleep influences immune function. Adequate sleep is essential for a healthy immune system. During sleep, the immune system is actively engaged in repairing and protecting the body. Sleep deprivation can weaken the immune response, making individuals more susceptible to infections.
Choice F rationale:
Sleep influences body temperature. The body's core temperature fluctuates during the sleep-wake cycle, with the lowest point typically occurring during the night when we are asleep. This temperature regulation is essential for sleep quality and overall health.
Choice G rationale:
Sleep influences renal function. Sleep has an impact on various physiological processes, including renal function. The kidneys play a role in regulating blood pressure and electrolyte balance, which can be influenced by sleep patterns.
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