A nurse is caring for a client who has a prescription for a fentanyl transdermal patch and had one patch applied 4 hr ago. The client reports breakthrough pain. Which of the following actions should the nurse take?

Provide a long-acting NSAID.

Apply heat to the patch.

Replace the patch with a new one.

Administer a short-acting opioid.

Answer and Explanation

The Correct Answer is D

A. A long-acting NSAID is not appropriate for breakthrough pain when a fentanyl patch is already in use, as it is not fast-acting enough.

B. Applying heat to the patch can increase the absorption of fentanyl, which could cause an overdose.

C. The fentanyl patch is a long-acting opioid, and a new patch should not be applied for breakthrough pain so soon.

D. A short-acting opioid is appropriate for treating breakthrough pain, as it provides rapid relief.

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Correct Answer is D

Explanation

A. Teaching about sodium is important but not an immediate action in response to weight gain.

B. Dangling the legs can help reduce edema but does not address the underlying cause of fluid retention.

C. Determining medication adherence is helpful but is secondary to addressing the acute concern of fluid retention.

D. Notifying the provider is the priority action. A 5 lb weight gain in 2 days may indicate fluid retention and worsening heart failure, requiring immediate intervention from the provider.

A. Increase the client's dietary intake of vitamin K. B. Teach the client that St. John's wort increases the effects of the medication. C. Administer protamine sulfate if the client experiences an overdose. D. Monitor the client's prothrombin time

Correct Answer is D

Explanation

A. Increasing dietary intake of vitamin K would decrease the effectiveness of warfarin, as vitamin K is involved in clotting factor synthesis.

B. St. John's wort decreases the effects of warfarin, so it should be avoided.

C. Protamine sulfate is the antidote for heparin, not warfarin. The antidote for warfarin overdose is vitamin K.

D. Monitoring prothrombin time (PT) and INR is essential to assess the effectiveness and safety of warfarin therapy.

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A nurse is caring for a client who has a prescription for a fentanyl transdermal patch and had one patch applied 4 hr ago. The client reports breakthrough pain. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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