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.

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Correct Answer is ["B","C","E"]

Explanation

The correct answer is B, C, and E.

A. Weight is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition.
B. Neuro status is a correct choice because it reflects the client's level of consciousness, orientation, memory, and cognitive function. Any alteration in neuro status could indicate a serious problem such as infection, stroke, or medication toxicity.
C. Auditory hallucinations are a correct choice because they are a symptom of psychosis and could indicate a relapse or worsening of the client's mental illness. Auditory hallucinations could also impair the client's ability to cope, communicate, and function effectively.
D. Speech is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition. Speech could be affected by various factors such as mood, anxiety, or medication side effects.
E. Restlessness is a correct choice because it is a sign of agitation, anxiety, or discomfort. Restlessness could also indicate an underlying physical or psychological problem such as pain, infection, or psychosis.

A. Lead 18 mcg/dL. B. Hemoglobin 12 g/dL. C. Iron 74 mcg/dL. D. Hematocrit 35%.

Correct Answer is A

Explanation

Choice A rationale:

A blood lead level of 18 mcg/dL in a 9-month-old infant is elevated. The Centers for Disease Control and Prevention (CDC) considers a blood lead level of 5 mcg/dL or higher in children to be concerning. Lead exposure can lead to developmental delays and cognitive impairments. Therefore, this result needs to be reported to the healthcare provider promptly.

Choice B rationale:

Hemoglobin level of 12 g/dL is within the normal range for a 9-month-old infant (11-15 g/dL) There is no need to report this result to the provider.

Choice C rationale:

Iron level of 74 mcg/dL is within the normal range for a 9-month-old infant (50-120 mcg/dL) There is no need to report this result to the provider.

Choice D rationale:

Hematocrit level of 35% is within the normal range for a 9-month-old infant (29-41%) There is no need to report this result to the provider.

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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

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Correct Answer is ["B","C","E"]

Explanation

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Correct Answer is A

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