A nurse is preparing a vitamin K injection to give to a newborn. The newborn's mother questions the purpose of the medication. Which of the following responses should the nurse make?

A. "This must be very frightening for you. Let's talk more about it.": This response demonstrates empathy and validation of the client's feelings, which can help build trust. It acknowledges the client's emotional state while not challenging or confronting their delusion directly. This approach helps maintain rapport while encouraging the client to express themselves.

B. "What makes you think the staff is following you?": This response could be perceived as questioning the validity of the client's experience, which may feel confrontational or invalidating. It is not the best approach for engaging a client with paranoid delusions.

C. “Why do you feel the staff is the FBI?": This question could also challenge the client's delusion and inadvertently reinforce their sense of being persecuted. Asking such a question might escalate anxiety rather than calm the client.

D. "The psychiatric staff is not FBI. They are here to help you.": While this response is factually correct, it may be perceived as dismissive of the client's experience. Confronting the delusion directly is generally not helpful and can increase the client's feelings of mistrust.

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.