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 ["A","B","D","E"]
Explanation
Choice A rationale:
Perception is one of the phases of nociceptive pain. It involves the awareness of pain, where the brain recognizes and interprets the pain signals. During this phase, the individual becomes conscious of the painful sensation.
Choice B rationale:
Transmission is another phase of nociceptive pain. It involves the propagation of pain signals from the site of injury or damage to the central nervous system. Nerve fibers carry the pain signals to the spinal cord and brain for processing.
Choice D rationale:
Modulation is also a phase of nociceptive pain. It refers to the body's ability to modify or regulate the pain signals. This can involve the release of endorphins or other natural pain-relieving substances that help dampen the pain perception.
Choice E rationale:
Transduction is the last phase of nociceptive pain. It is the process where the noxious stimulus (injury or damage) is converted into electrical nerve signals that the body can understand. This conversion allows the pain signal to travel through the nervous system.
Choice C rationale:
Translation is not typically considered one of the phases of nociceptive pain. While translation may refer to the process of converting one form of information to another, it is not a recognized phase in the context of pain perception.
Correct Answer is A
Explanation
Choice A rationale:
IM injections of pain medication may be contraindicated for patients who have small, poorly developed muscles. The rationale for this is that IM injections require adequate muscle mass to ensure proper absorption and distribution of the medication. If a patient has small, poorly developed muscles, the injection may not be as effective, and there's a risk of improper medication delivery, which can lead to reduced pain relief and potential complications.
Choice B rationale:
IM injections are not primarily contraindicated for patients based on their cognitive abilities. However, the patient's cognitive abilities may affect their ability to understand and follow instructions related to the injection process. It's essential for healthcare providers to ensure that the patient comprehends the procedure and can cooperate. Patients with cognitive impairments may require additional assistance or alternative methods of pain management, but it's not a direct contraindication to IM injections.
Choice C rationale:
Needing short-term pain management is not a contraindication for IM injections of pain medication. IM injections can be suitable for short-term pain relief, as they can provide relatively rapid and effective pain control. The choice of pain management method should depend on the specific circumstances and the patient's condition, but the duration of pain management needed is not a direct contraindication to IM injections.
Choice D rationale:
Having multiple drug allergies can be a concern when considering IM injections of pain medication, but it is not a direct contraindication. The healthcare provider should carefully assess the patient's allergies and select a medication that is safe and appropriate for the individual. In some cases, alternative routes of administration may be considered to avoid allergenic reactions. However, having multiple drug allergies alone does not necessarily contraindicate IM injections.
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