The nurse performing a focused assessment on pain will assess: (Select all that apply.).

Choice A rationale:

If a patient with a Fentanyl patch is experiencing symptoms like abnormal sleepiness, slurred speech, and unsteadiness when ambulating, it could indicate an overdose or adverse reaction to the Fentanyl. In such cases, the patch should be removed immediately to stop the further absorption of the drug. Wiping off the skin can also help remove any residual medication. This is the correct choice as it addresses the issue at its source.

Choice B rationale:

Applying ice to the skin around the Fentanyl patch is not the appropriate action in this situation. Ice will not counteract the effects of a Fentanyl overdose or adverse reaction. The priority is to remove the patch and seek medical attention.

Choice C rationale:

Elevating the head of the bed and offering coffee or cola may be useful in combating some forms of sleepiness but would not be effective for someone experiencing an overdose or adverse reaction to Fentanyl. This choice does not address the problem's root cause and is not the appropriate action to take.

Choice D rationale:

Putting up the side rails on the bed does not address the issue of Fentanyl patch overdose or adverse reactions. This choice is not relevant to the situation and should not be chosen.

Choice A rationale:

Placing electrodes on all four extremities is not the initial step in using a Transcutaneous Electrical Nerve Stimulator (TENS) unit. It may not be necessary for the specific pain management needs of the patient and can be uncomfortable or impractical.

Choice B rationale:

This is the correct initial step when starting TENS treatment. The nurse should adjust the settings to a level below the threshold at which the patient feels a tingling sensation. This ensures that the treatment is comfortable and safe for the patient. The goal is to provide pain relief, not to induce discomfort.

Choice C rationale:

Turning the unit on before attaching it to the patient is not advisable. It's essential to connect the electrodes to the patient first and then turn on the TENS unit. This sequence helps prevent accidental electrical stimulation before the device is properly set up.

Choice D rationale:

Applying conductive jelly to uncoated electrodes is a step in preparing the electrodes for use, but it should be done after attaching the electrodes to the patient's skin. This choice does not address the initial step in TENS treatment, which is setting the stimulation level. .