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 D
Explanation
Choice A rationale:
Using heavy pressure on the cold pack for greater effectiveness is not the correct approach when applying a cold pack to an injured area. Applying excessive pressure can lead to tissue damage, frostbite, and can be uncomfortable for the patient. Cold packs should be applied with gentle, even pressure to avoid complications.
Choice B rationale:
Leaving the cold pack in place for over 30 minutes at a time is not recommended. Prolonged exposure to cold can also cause tissue damage, including frostbite. It is generally advised to limit cold pack applications to 20-30 minutes at a time to prevent complications.
Choice C rationale:
Preparing to apply heat instead if cold is not effective is not the appropriate action in this scenario. When a healthcare provider orders a cold pack application, it is essential to follow the prescribed treatment plan. Heat should only be considered if it is specifically ordered as an alternative treatment.
Choice D rationale:
Placing a towel between the pack and the skin is the correct approach to prevent patient injury when applying a cold pack. This helps to protect the skin from direct contact with the cold pack, reducing the risk of frostbite or cold-related injuries. It ensures a barrier between the cold pack and the patient's skin, providing a safe and comfortable application.
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