A nurse is preparing to administer fentanyl 100 mcg via IV bolus to a client who is postoperative and is currently receiving 0.9% sodium chloride by continuous IV infusion. Which of the following actions should the nurse take?

Flush the port with heparin prior to administering the medication.

Inject the medication into the port closest to the client.

Pinch the tubing below the injection port prior to administration.

Administer the medication over 10 seconds.

Answer and Explanation

The Correct Answer is B

A. Flush the port with heparin prior to administering the medication. Heparin is not typically used to flush the port before administering IV medications; saline is generally used for flushing.
B. Inject the medication into the port closest to the client. This ensures the medication is delivered quickly and effectively, minimizing dilution and maximizing its effect.
C. Pinch the tubing below the injection port prior to administration. Pinching the tubing can help ensure the medication goes into the client quickly but should be done only if specified by protocol.
D. Administer the medication over 10 seconds. Fentanyl should be administered slowly over 1-2 minutes to prevent rapid administration-related side effects like hypotension or respiratory depression.

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Correct Answer is B

Explanation

A. Ask the staff members to speak in much quieter tones. This does not fully address the issue. HIPAA regulations prohibit discussing patient information in public areas regardless of the volume.
B. Tell the staff members to stop discussing confidential information about this client. This is correct. This action directly addresses the breach of confidentiality and promotes HIPAA regulations by stopping the inappropriate discussion.
C. Alert the facility's attorney about the staff members' breach of confidentiality. This action may be excessive and is not the immediate step needed to stop the breach. Reporting to a supervisor or manager is more appropriate.
D. Ignore the situation because there is no one close by to hear the staff members' discussion. This is incorrect. Ignoring the situation does not comply with HIPAA regulations, which require confidentiality regardless of whether anyone is nearby.

A. Tingling in the toes B. 1+ dorsalis pedis pulse C. Capillary refill of 3 seconds D. Increased edema of the foot

Correct Answer is D

Explanation

A. Tingling in the toes: Tingling in the toes is not specific to CRPS. It might be a general symptom but is not a classic sign of CRPS.
B. 1+ dorsalis pedis pulse: A weak pulse might indicate reduced circulation but is not specific to CRPS. CRPS is more associated with pain, swelling, and changes in skin color or temperature.
C. Capillary refill of 3 seconds: A capillary refill time of 3 seconds is prolonged and suggests possible circulation issues, but it is not a specific manifestation of CRPS.
D. Increased edema of the foot: Increased edema of the foot is a common manifestation of CRPS. CRPS often presents with localized swelling, along with other symptoms like pain and changes in skin color or temperature.

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A nurse is preparing to administer fentanyl 100 mcg via IV bolus to a client who is postoperative and is currently receiving 0.9% sodium chloride by continuous IV infusion. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse overhears two staff members in a public hallway discussing the diagnosis of a client on another unit. Which of the following actions should the nurse take to promote HIPAA regulations?

Correct Answer is B

Explanation

A nurse is assessing a client who has an ankle fracture of the right foot and is at risk for complex regional pain syndrome (CRPS). The nurse should identify that which of the following findings is a manifestation of CRPS?

Correct Answer is D

Explanation

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