A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take?
Withhold pain medications for 24 hr after the old patch is removed.
Ask another nurse to witness the disposal of the new patch.
Seal the patches in a plastic bag and place in the client's trash basket.
Stick the two patches to each other and place them in the sharps bin.
The Correct Answer is B
A. Incorrect. Withholding pain medications for 24 hr after the old patch is removed is a harmful action that could cause severe withdrawal symptoms and uncontrolled pain for the client. The nurse should respect the client's right to refuse treatment and explore the reasons for their decision.
B. Correct. Asking another nurse to witness the disposal of the new patch is a safe and legal action that follows the policies and procedures for handling controlled substances. The nurse should document the disposal of the new patch and report it to the appropriate authority.
C. Incorrect. Sealing the patches in a plastic bag and placing them in the client's trash basket is an unsafe and illegal action that could lead to diversion, misuse, or accidental exposure of fentanyl to others. The nurse should dispose of the patches in a secure and designated container that prevents access by unauthorized persons.
D. Incorrect. Sticking the two patches to each other and placing them in the sharps bin is an unsafe and improper action that could cause contamination, injury, or infection to others who handle or dispose of sharps waste. The nurse should dispose of the patches separately and carefully, avoiding contact with their adhesive surfaces.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason
Increased food intake does not show medication is effective: Increased food intake is not a specific indication of donepezil's effectiveness. While some clients with dementia may have improved appetite due to reduced agitation or confusion, it is not directly related to the medication's therapeutic effect.
Choice B reason:
Can perform ADLs independently is inappropriate: The ability to perform activities of daily living (ADLs) independently can be a positive outcome in clients with dementia. However, it may not be solely attributed to donepezil, as ADLs can be influenced by various factors, including the client's overall condition and support received.
Choice C reason:
Improved short-term memory is correct. One of the primary goals of using donepezil is to improve memory and slow the decline in cognitive abilities associated with dementia. Therefore, if a client shows improvement in short-term memory, it suggests that the medication is having a positive effect in preserving cognitive function.
Choice D reason
Enhanced mood does not show the medicine is effective: Donepezil is primarily aimed at improving cognitive function and memory, and its effects on mood may be limited. While some clients may experience mood improvements due to reduced frustration or confusion from memory loss, it is not the primary indicator of the medication's effectiveness.
Correct Answer is B
Explanation
Choice A reason:
Natural loss of deciduous teeth is incorrect. Natural loss of deciduous teeth, also known as baby teeth, usually begins around the age of 5 or 6 years. At the age of 2, a toddler would still have their baby teeth.
Choice B reason:
This is a normal finding in toddlers. It is common for toddlers to have a protruding abdomen due to their body composition and the normal development of their abdominal muscles.
Choice C reason:
Head circumference exceeds chest circumference: In a typical 2-year-old toddler, the head circumference should be less than the chest circumference. The head grows rapidly during infancy and slows down as the child grows older, leading to a cage in the head-to-chest ratio.
Choice D reason:
The fontanels, or soft spots on the skull, usually close by the end of the first year. By age 2, the fontanels should be closed or very close to being closed, and they would not typically be palpable.
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