When preparing to apply a scheduled fentanyl transdermal patch, the nurse notes that the previously applied patch is intact on the client’s upper back and the client denies pain. Which action should the nurse take?

Place the patch on the client’s shoulder and leave both patches in place for 12 hours.

Remove the patch and consult with the healthcare provider about the client’s pain resolution.

Apply the new patch in a different location after removing the original patch.

Administer an oral analgesic and evaluate its effectiveness before applying the new patch.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Placing the new patch on the client’s shoulder and leaving both patches in place for 12 hours is not recommended. Fentanyl patches are designed to be used one at a time, and overlapping patches can lead to an overdose due to excessive absorption of the medication1. The standard practice is to remove the old patch before applying a new one.

Choice B reason:

Removing the patch and consulting with the healthcare provider about the client’s pain resolution is a cautious approach. However, it is not necessary to consult the healthcare provider if the client denies pain and the patch is due for replacement. The nurse should follow the standard protocol for patch replacement.

Choice C reason:

Applying the new patch in a different location after removing the original patch is the correct action. This ensures that the medication is delivered effectively while preventing skin irritation and potential overdose. The new patch should be placed on a different area of intact skin to allow the previous site to recover.

Choice D reason:

Administering an oral analgesic and evaluating its effectiveness before applying the new patch is not appropriate in this scenario. The client is already receiving pain management through the transdermal patch, and additional oral analgesics are not necessary unless there is breakthrough pain. The focus should be on proper patch replacement

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Correct Answer is A

Explanation

Choice A Reason:

Contact the healthcare provider: Given the client’s history of anaphylactic reaction to penicillin, there is a potential risk of cross-reactivity with cephalexin, a cephalosporin. Although the risk of cross-reactivity is relatively low, it is still significant enough to warrant caution. Studies indicate that 1-4% of people with a true penicillin allergy may also react to cephalosporins. Therefore, the nurse should contact the healthcare provider to discuss alternative antibiotics or additional precautions.

Choice B Reason:

Give with prescribed antihistamine: While antihistamines can help manage mild allergic reactions, they are not sufficient to prevent or treat anaphylaxis. Anaphylactic reactions require immediate medical intervention, including epinephrine administration. Therefore, relying solely on antihistamines is not an appropriate or safe action in this scenario.

Choice C Reason:

Administer the medication as prescribed: Administering cephalexin without consulting the healthcare provider could put the client at risk of a severe allergic reaction. Given the client’s history of anaphylaxis to penicillin, it is crucial to verify the safety of cephalexin with the healthcare provider before administration.

Choice D Reason:

Monitor the client for a rash or hives: While monitoring for allergic reactions is essential, it should not be the primary action in this case. The priority is to prevent a potential severe allergic reaction by consulting the healthcare provider before administering the medication. Monitoring alone does not address the underlying risk of cross-reactivity.

A. Assess the client’s strength in moving and turning in the bed. B. Determine the frequency and consistency of bowel movements. C. Observe the skin integrity of the client’s rectal and sacral areas. D. Evaluate the client’s ability to recognize the urge to defecate.

Correct Answer is B

Explanation

Choice A reason: Assessing the client’s strength in moving and turning in bed is important for overall care, but it is not the primary assessment needed before administering a laxative. This assessment helps in understanding the client’s mobility and risk of pressure ulcers but does not directly relate to the effectiveness or necessity of a laxative.

Choice B reason: Determining the frequency and consistency of bowel movements is crucial before administering a laxative. This assessment provides information on the client’s current bowel function and helps in deciding the appropriate type and dosage of laxative. It ensures that the laxative is necessary and helps prevent complications such as diarrhea or bowel obstruction.

Choice C reason: Observing the skin integrity of the client’s rectal and sacral areas is important for preventing pressure ulcers and maintaining skin health, especially in bedfast clients. However, this assessment is not directly related to the administration of a laxative. It is more relevant to overall skin care and prevention of pressure sores.

Choice D reason: Evaluating the client’s ability to recognize the urge to defecate is important for understanding their bowel habits and potential issues with incontinence. However, it is not the primary assessment needed before administering a laxative. This assessment is more relevant to managing bowel training and incontinence.

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When preparing to apply a scheduled fentanyl transdermal patch, the nurse notes that the previously applied patch is intact on the client’s upper back and the client denies pain. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of anaphylactic reaction to penicillin receives a prescription for cephalexin 500 mg PO twice daily. Which action should the nurse take?

Correct Answer is A

Explanation

Before administering a laxative to a bedfast client, it is most important for the nurse to perform which assessment?

Correct Answer is B

Explanation

A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in the client’s plan of care?

Prior to administering an oral dose of methylprednisolone, the nurse determines the client’s serum total calcium level is 5.5 mg/dL (1.375 mmol/L). What action is most important for the nurse to take?

Which laboratory value should the nurse review prior to administering the initial dose of a statin medication?

A client with multiple sclerosis starts a new prescription, baclofen, to control muscle spasticity. Three days later, the client calls the clinic nurse and reports feeling fatigued and dizzy. Which instruction should the nurse provide?

A patient with peptic ulcer disease is scheduled to receive doses of pantoprazole IV and sucralfate PO before breakfast at 0800. The patient reports experiencing heartburn. The nurse brings the scheduled medications. Which action should the nurse take?

A client is receiving tamsulosin, an alpha-adrenergic blocking agent, for the management of urinary retention due to benign prostatic hyperplasia (BPH). Which instruction is most important for the nurse to provide?

A client who has been taking nonsteroidal anti-inflammatory drugs (NSAIDs) is experiencing gastric pain and blood in his stool. The healthcare provider discontinues the NSAIDs and prescribes esomeprazole. Which information should the nurse include in this client’s teaching plan?

A client with chronic kidney disease (CKD) is receiving calcium acetate 667 mg PO. A decrease in which blood value indicates to the nurse that the medication is having the desired effect?