A nurse is caring for a client who has a new prescription for a fentanyl transdermal patch. Which of the following actions should the nurse take when administering a transdermal patch? (Select all that apply.)

Apply the transdermal patch to either of the client's forearms.

Remove the old transdermal patch before applying a new one.

Apply the patch to a clean, hairless area of the client's skin.

Use sterile gloves to apply and remove transdermal patches.

Dispose of old transdermal patches in a childproof container.

Answer and Explanation

Correct Answer : B,C,E

A. "Apply the transdermal patch to either of the client's forearms" is incorrect. The nurse should avoid applying the patch to areas with excessive hair, irritation, or broken skin. Common areas include the upper torso (e.g., upper arm, chest, or back).

B. "Remove the old transdermal patch before applying a new one" is correct. To prevent overdose or accidental administration of an additional dose, the nurse should always remove the old patch before applying a new one.

C. "Apply the patch to a clean, hairless area of the client's skin" is correct. This ensures better adhesion and absorption of the medication, as hair and dirt can interfere with the patch's effectiveness.

D. "Use sterile gloves to apply and remove transdermal patches" is incorrect. Standard gloves are sufficient for applying and removing transdermal patches, as they do not need to be sterile.

E. "Dispose of old transdermal patches in a childproof container" is correct. Fentanyl patches should be disposed of properly to avoid accidental exposure or ingestion by children or pets. A childproof container ensures safe disposal.

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Correct Answer is B

Explanation

A. "Give the client a straw to use for drinking" is incorrect. Straws are not recommended for clients with dysphagia because they can increase the risk of aspiration. It is better to use a cup to control the amount of liquid ingested and reduce choking risk.

B. "Place oral suction equipment next to the client's bedside" is correct. For clients with dysphagia, having oral suction equipment readily available can help clear the airway quickly in case of aspiration or choking. It is an important safety measure in the management of dysphagia.

C. "Provide thin liquids to help the client swallow" is incorrect. Thin liquids can increase the risk of aspiration for clients with dysphagia. It is often recommended to provide thickened liquids, as they are easier to swallow and less likely to be aspirated.

D. "Use a needleless syringe to instill feedings" is incorrect. The use of a needleless syringe for feeding is generally not appropriate for clients with dysphagia unless specifically recommended for feeding via a tube. Otherwise, feeding should be done carefully with consideration for the type and consistency of the food.

A. Elevated blood pressure B. Bounding pulse C. Fruity breath odor D. Clammy skin

Correct Answer is C

Explanation

A. Elevated blood pressure: Diabetic ketoacidosis (DKA. typically does not cause elevated blood pressure. In fact, due to dehydration from increased urination, clients often present with hypotension or normal blood pressure, rather than hypertension.

B. Bounding pulse: A bounding pulse is not commonly associated with DKA. It may be seen with conditions such as fever or sepsis, but DKA is more likely to cause a weak or thready pulse due to fluid volume deficit and dehydration.

C. Fruity breath odor: A fruity or acetone-like breath odor is a hallmark sign of diabetic ketoacidosis. This is caused by the presence of ketones in the blood, which are produced as the body breaks down fat for energy when glucose is unavailable.

D. Clammy skin: Clammy skin is more likely to be associated with hypoglycemia, not DKA. In DKA, the skin is typically dry due to dehydration, and the client may appear flushed, not clammy.

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A nurse is caring for a client who has a new prescription for a fentanyl transdermal patch. Which of the following actions should the nurse take when administering a transdermal patch? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a history of dysphagia. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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