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 D
Explanation
Choice A rationale:
Bringing a newspaper or deck of cards does not directly relate to guided imagery, which is a technique used to help patients manage pain through visualization. It's important to provide interventions that align with the patient's expressed preference and pain management goals.
Choice B rationale:
Finding a focal point in the room is not directly related to guided imagery. While it may be helpful for relaxation in some cases, it's not a specific technique for guiding a patient through visualization to manage pain.
Choice C rationale:
Obtaining skin lotion and a towel for a back rub is not related to guided imagery, and it assumes the patient's preference without considering the patient's previously mentioned benefit from guided imagery.
Choice D rationale:
Reading from a script that helps the patient visualize a restful place aligns with the practice of guided imagery. This technique can be effective in helping patients manage pain by redirecting their focus and promoting relaxation. It's a suitable intervention based on the patient's past experience and preferences. .
Correct Answer is B
Explanation
The correct answer is B. Responsibility.
Choice A rationale:
“Fairness.” Fairness involves treating all clients equally and without bias. While fairness is an important aspect of professionalism, it is not specifically demonstrated by evaluating the effectiveness of pain medication.
Choice B rationale:
“Responsibility.” Responsibility refers to the nurse’s duty to provide safe and effective care. By checking the client to evaluate the effectiveness of pain medication, the nurse is fulfilling their responsibility to monitor the client’s response to treatment and ensure their comfort and well-being.
Choice C rationale:
“Confidence.” Confidence involves the nurse’s self-assurance in their skills and knowledge. While confidence is important in nursing practice, it is not the primary component demonstrated in this scenario.
Choice D rationale:
“Advocacy.” Advocacy involves supporting and speaking up for the client’s needs and preferences. Although advocacy is a crucial part of nursing, the act of evaluating pain medication effectiveness is more directly related to the nurse’s responsibility to provide appropriate care.
By demonstrating responsibility, the nurse ensures that the client’s pain management is effective and that any necessary adjustments to the treatment plan are made.
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