A nurse is assessing a client who has a transdermal fentanyl patch in place. Which of the following findings should the nurse document as an adverse effect of this medication?
Hypotension
Tachycardia
Diarrhea
Insomnia
The Correct Answer is A
A. Hypotension: Hypotension can occur as an adverse effect of fentanyl, particularly if the client experiences excessive sedation or respiratory depression. Fentanyl is a potent opioid analgesic
that can cause vasodilation and a decrease in blood pressure, especially when used in high doses or in susceptible individuals.
B. Tachycardia: Tachycardia is not a typical adverse effect of fentanyl. Opioids like fentanyl typically cause bradycardia or have minimal effects on heart rate.
C. Diarrhea: Diarrhea is not a common adverse effect of fentanyl. Opioids more commonly cause constipation due to their effects on gastrointestinal motility.
D. Insomnia: Insomnia is not a typical adverse effect of fentanyl. Opioids typically cause sedation and can lead to drowsiness or somnolence, especially during initial use or when administered in high doses.
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Related Questions
Correct Answer is C
Explanation
A. Urinary retention: While urinary retention can be a complication of epidural anesthesia, it is not the priority finding in this scenario. The priority is to address potential complications that can lead to maternal or fetal compromise.
B. Leg weakness: Leg weakness can occur as a side effect of epidural anesthesia but is not the priority finding in this scenario unless it is severe and compromises the client's ability to
mobilize or push during labor.
C. Hypotension: Hypotension is a common complication of epidural anesthesia due to sympathetic blockade, which can lead to decreased venous return and subsequent maternal
hypotension. Maternal hypotension can compromise uteroplacental perfusion, leading to fetal distress. Therefore, addressing hypotension promptly is the priority to prevent adverse maternal and fetal outcomes.
D. Temperature 39°C (102.2°F): While fever should be monitored and addressed, it is not the priority finding in this scenario unless it indicates an infection, which would require further assessment and intervention. However, maternal hypotension poses a more immediate risk to both the mother and the fetus during labor.
Correct Answer is C
Explanation
A. An increased heart rate can be a sign of dehydration and would not indicate that IV fluid replacement has been effective.
B. Excessive thirst is a symptom of dehydration and would not indicate that IV fluid replacement has been effective.
C. Moist oral mucous membranes indicate improved hydration status and are a positive response to IV fluid replacement.
D. Decreased blood pressure is a sign of dehydration and would not indicate that IV fluid replacement has been effective.
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