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 C
Explanation
Choice A rationale:
Keeping bright lights on in the room is not conducive to relaxation. Bright lights can be stimulating and may increase stress, which is counterproductive when trying to manage pain through relaxation techniques.
Choice B rationale:
Using relaxation techniques as a way to wake up in the morning is not the intended purpose of these techniques. Relaxation techniques are typically used to reduce stress, anxiety, and pain, especially when one is trying to rest or sleep.
Choice C rationale:
Tensing and relaxing individual muscle groups, starting with the toes and feet, is a common method for progressive muscle relaxation. This technique can help reduce muscle tension and promote overall relaxation. It is an effective approach to pain management.
Choice D rationale:
Trying to tense and relax all of the muscles of the body at the same time may be difficult for most individuals and is not a commonly recommended relaxation technique. It can be challenging to achieve the level of focus and control required for this method, and it may not be as effective as focusing on individual muscle groups.
Correct Answer is C
Explanation
The correct answer is: C. Decreased energy.
Choice A reason: Hypotension is not typically associated with obstructive sleep apnea (OSA). OSA is more commonly linked with hypertension due to the frequent arousals during sleep that activate the sympathetic nervous system, leading to increased blood pressure.
Choice B reason: Pneumonia is an infection of the lungs and is not a direct consequence of OSA. While OSA can affect the respiratory system, it does not cause pneumonia. However, individuals with OSA may have a higher risk of respiratory infections due to compromised breathing during sleep.
Choice C reason: Decreased energy is a common symptom of OSA. People with OSA experience repeated episodes of partial or complete upper airway obstruction during sleep, leading to disrupted sleep patterns and insufficient rest. This results in daytime sleepiness and fatigue, which are hallmark signs of the condition.
Choice D reason: Thyroid disease, specifically hypothyroidism, can be associated with OSA, but it is not a direct finding of the condition. Hypothyroidism can lead to changes in the soft tissues of the upper airway and contribute to the development of OSA, but it is not a symptom used to diagnose OSA.
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