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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B, A, D, C

Explanation

B. Inspection is the first step in an abdominal assessment because it allows the nurse to observe the shape, size, symmetry, contour, and movement of the abdomen. Inspection also helps to identify any abnormalities such as scars, lesions, masses, or distension.

A. Auscultation is the second step in an abdominal assessment because it allows the nurse to listen to the bowel sounds and vascular sounds of the abdomen. Auscultation should be performed before palpation or apercussion because these maneuvers could alter the sounds.

D. Percussion is the third step in an abdominal assessment because it allows the nurse to elicit sounds from different organs and structures in the abdomen. Percussion helps to determine the size, location, density, and consistency of the organs and to detect any fluid or air accumulation.

C. Palpation is the last step in an abdominal assessment because it allows the nurse to feel the texture, temperature, tenderness, and masses of the abdomen. Palpation should be performed gently and carefully to avoid causing pain or injury to the client.

A. Hemoglobin 14.9 g/dL B. WBC count 12.000/mm C. Potassium 48 mEq D. BUN 18 mg/dL

Correct Answer is A

Explanation

A. Correct. A hemoglobin level of 14.9 g/dL indicates that the client has an adequate amount of oxygen-carrying capacity in the blood, which is the goal of blood transfusion therapy.

B. Incorrect. A WBC count of 12,000/mm3 is slightly elevated and may indicate an infection or inflammation, which are not related to blood transfusion therapy.

C. Incorrect. A potassium level of 48 mEq/L is dangerously high and may cause cardiac arrhythmias, muscle weakness, or paralysis. This is not an expected outcome of blood transfusion therapy and may indicate hemolysis or renal impairment.

D. Incorrect. A BUN level of 18 mg/dL is within the normal range and does not reflect the effectiveness of blood transfusion therapy.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take.

Correct Answer is B, A, D, C

Explanation

A nurse is assessing a client who received 2 units of packed RBCs 48 hr ago. Which of the following findings should indicate to the nurse that the therapy has been effective?

Correct Answer is A

Explanation

A nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching?

The practical nurse (PN) is caring for a client whose urine drug screen is positive for cocaine. Which behavior is most likely seen in this client?

A school nurse is performing scoliosis screenings. The nurse should recognize which of the following clinical manifestations as an indication of scoliosis?

A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload?

A nurse is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider?

A nurse preceptor is evaluating the performance of a newly licensed nurse. Which of the following actions by the newly licensed nurse requires intervention by the preceptor?

A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take?