A nurse caring for a patient with a Fentanyl patch assesses that the patient is abnormally sleepy, is slurring words, and is unsteady when ambulating.
The nurse should:.

remove the patch and wipe off the skin.

apply ice to the skin around the patch.

elevate the head of the bed 45 degrees and offer coffee or cola drink.

put up the side rails on the bed.

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is B

Explanation

Choice A rationale:

A patient with a decreased level of consciousness from a stroke may not be able to provide feedback or recognize discomfort or pain, which can increase the risk of burn injury when using a heating pad. This choice increases the risk rather than reducing it.

Choice B rationale:

A patient with neuritis secondary to diabetes has a decreased sensitivity in the affected area due to nerve damage. While this can be a challenging condition, it reduces the patient's ability to perceive heat and pain, making them less likely to realize if the heating pad becomes too hot. As a result, this patient has the least risk for burn injury when using the Aquathermia K pad.

Choice C rationale:

A severely sprained ankle is not related to the risk of burn injury from a heating pad. This choice is not relevant to the assessment of burn injury risk with the Aquathermia K pad.

Choice D rationale:

Impaired peripheral circulation can increase the risk of burn injury from a heating pad. Patients with compromised circulation have a reduced ability to dissipate heat, which can lead to localized overheating and potential burn injury. This choice increases the risk of injury. .

A. "A large dose of pain medication is administered with each injection.”. B. "You will have control of administering your own pain medication.”. C. "Your partner can push the PCA button for you if you are asleep.”. D. "The pain medication is delivered into your muscle.”.

Correct Answer is B

Explanation

Choice A rationale:

This statement is not accurate and may confuse the client. In a Patient-Controlled Analgesia (PCA) system, a predetermined dose is delivered when the patient activates the device. The dose is usually controlled to prevent excessive medication administration.

Choice B rationale:

This statement is correct. The essence of PCA is that the patient has control over administering their pain medication within set limits or time intervals. The patient can self-administer doses when needed, ensuring effective pain management.

Choice C rationale:

Allowing the partner to push the PCA button for the patient is not recommended. PCA systems are designed to be controlled by the patient themselves to prevent potential overdosing. Involving someone else in the administration can lead to safety concerns.

Choice D rationale:

PCA systems do not deliver medication into the muscle. They typically deliver medication intravenously (IV) or subcutaneously. This statement is inaccurate and could lead to misconceptions about how the PCA system works.

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A nurse caring for a patient with a Fentanyl patch assesses that the patient is abnormally sleepy, is slurring words, and is unsteady when ambulating.The nurse should:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse evaluating the effectiveness of an Aquathermia K pad for the leg is aware that the patient who has the least risk for burn injury from this device would be the patient with:.

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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A nurse caring for a patient with a Fentanyl patch assesses that the patient is abnormally sleepy, is slurring words, and is unsteady when ambulating.The nurse should:.

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A nurse caring for a patient with a Fentanyl patch assesses that the patient is abnormally sleepy, is slurring words, and is unsteady when ambulating.
The nurse should:.