A nurse is caring for a client who has a new prescription for a fentanyl transdermal patch. Which of the following actions should the nurse take when administering a transdermal patch? (Select all that apply.)

Apply the transdermal patch to either of the client's forearms.

Remove the old transdermal patch before applying a new one.

Apply the patch to a clean, hairless area of the client's skin.

Use sterile gloves to apply and remove transdermal patches.

Dispose of old transdermal patches in a childproof container.

Answer and Explanation

Correct Answer : B,C,E

A. "Apply the transdermal patch to either of the client's forearms" is incorrect. The nurse should avoid applying the patch to areas with excessive hair, irritation, or broken skin. Common areas include the upper torso (e.g., upper arm, chest, or back).

B. "Remove the old transdermal patch before applying a new one" is correct. To prevent overdose or accidental administration of an additional dose, the nurse should always remove the old patch before applying a new one.

C. "Apply the patch to a clean, hairless area of the client's skin" is correct. This ensures better adhesion and absorption of the medication, as hair and dirt can interfere with the patch's effectiveness.

D. "Use sterile gloves to apply and remove transdermal patches" is incorrect. Standard gloves are sufficient for applying and removing transdermal patches, as they do not need to be sterile.

E. "Dispose of old transdermal patches in a childproof container" is correct. Fentanyl patches should be disposed of properly to avoid accidental exposure or ingestion by children or pets. A childproof container ensures safe disposal.

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Correct Answer is C

Explanation

A. "Wear sterile gloves when in contact with body fluids" is incorrect. While sterile gloves are necessary for sterile procedures, clean gloves are generally sufficient for contact with body fluids. The main focus of hand hygiene is on proper handwashing techniques.

B. "Use alcohol-based cleanser when hands are visibly soiled" is incorrect. Alcohol-based hand sanitizers should not be used when hands are visibly soiled, as they are less effective in removing dirt, grease, or organic material. Soap and water are needed for visibly soiled hands.

C. "Wash hands with soap and water for 20 seconds" is correct. The recommended duration for handwashing is 20 seconds, which is sufficient for removing pathogens effectively. This is standard practice for maintaining proper hand hygiene in healthcare settings.

D. "Artificial nails can be worn when performing direct client care" is incorrect. Artificial nails and chipped nail polish are contraindicated in healthcare settings because they can harbor bacteria and increase the risk of infection transmission.

A. Productive cough with pink, frothy sputum B. Weight loss of 1 kg (2.2 lB. in the past 24 hr C. Fatigue when ambulating 152 m (500 ft)

Correct Answer is A

Explanation

A. "Productive cough with pink, frothy sputum": This is a concerning finding that should prompt immediate notification to the provider. It is indicative of pulmonary edema, which can occur with left-sided heart failure as fluid backs up into the lungs. Pink, frothy sputum is a classic sign of this condition and requires urgent intervention.

B. "Weight loss of 1 kg (2.2 lB. in the past 24 hr": Weight loss is generally not a primary concern in left-sided heart failure. In fact, weight loss could be a result of fluid loss from diuretics or other interventions. A small weight change like this is not likely to be significant unless the client shows signs of dehydration or malnutrition.

C. "Fatigue when ambulating 152 m (500 ft)": Fatigue with activity is common in clients with left-sided heart failure, as reduced cardiac output and impaired oxygenation of tissues can cause fatigue during exertion. However, this is not an acute finding that would require immediate intervention.

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A nurse is caring for a client who has a new prescription for a fentanyl transdermal patch. Which of the following actions should the nurse take when administering a transdermal patch? (Select all that apply.)

Nursing Test Bank

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