A nurse is assisting with teaching a client who has obstructive sleep apnea (OSA) about continuous positive airway pressure (CPAP). Which of the following instructions should the nurse include?

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.

Choice A rationale:
Increasing pain over several hours is not a typical sign of a fentanyl patch overdose. Fentanyl is a potent opioid, and overdose symptoms often involve respiratory depression, altered mental status, and other serious issues. While it is possible for a patient to experience increased pain if the fentanyl patch is not providing adequate pain relief, this is not a specific sign of overdose.
Choice B rationale:
An itchy red rash on the skin is not a sign of a fentanyl patch overdose but can be associated with skin irritation or allergies to the adhesive in the patch. It's important to differentiate between a skin reaction and an overdose when evaluating patients using fentanyl patches. Overdose symptoms are more severe and life-threatening.
Choice C rationale:
Confusion and the inability to walk normally are characteristic signs of a fentanyl patch overdose. Fentanyl is a potent opioid, and overdose can lead to central nervous system depression, resulting in confusion, altered mental status, and difficulty with coordination and walking. These symptoms are serious and require immediate medical attention.
Choice D rationale:
Headache and nausea are not specific signs of a fentanyl patch overdose. While opioid overdose can cause various symptoms, such as respiratory depression and altered mental status, headache and nausea are not among the primary indicators. However, individual responses to medications can vary, and some patients may experience these symptoms as part of a broader set of overdose signs.