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 A

Explanation

A. A negative pressure room is correct. Varicella zoster, which causes chickenpox, is an airborne virus. Therefore, airborne precautions are required, which include placing the client in a negative pressure room to prevent the spread of the virus to other areas of the facility.

B. Administering aspirin is incorrect. Aspirin should not be given to children or adolescents with varicella zoster due to the risk of Reye's syndrome. Instead, an antipyretic such as acetaminophen should be used to treat fever.

C. Contact precautions are not sufficient for varicella zoster, as the virus requires airborne precautions to prevent transmission through the air.

D. Having visitors remain at least 0.91 m (3 feet) away is incorrect. Airborne precautions require that visitors wear appropriate PPE, including respirators, and should not be restricted to 3 feet away. Ideally, visitors should wear full protective gear when entering the room.

A. Client-stated, "I lost my balance and fell when I got out of bed to go to the bathroom." B. "An incident report has been completed and sent to risk management." C. "The client fell because the assistive personnel did not place nonskid slippers on the client." D. "The client does not appear to have any injuries resulting from the fall."

Correct Answer is A

Explanation

A. Client-stated, "I lost my balance and fell when I got out of bed to go to the bathroom." This is the correct choice. The nurse should document the client's own account of the event in the medical record. It is important to accurately record the client's statement, as documentation should reflect the facts and avoid interpretation or assumptions.

B. "An incident report has been completed and sent to risk management." This statement should not be included in the client's medical record. Incident reports are separate from clinical documentation and are not part of the patient's permanent medical record.

C. "The client fell because the assistive personnel did not place nonskid slippers on the client." This statement makes an assumption about the cause of the fall and includes blame, which is inappropriate for medical documentation. Documentation should focus on objective observations and the client's statement, not assigning fault.

D. "The client does not appear to have any injuries resulting from the fall." While the nurse may assess the client for injuries, this statement should not be included unless it is confirmed and part of a thorough, objective assessment. It’s important to document specific findings (e.g., "No visible injuries noted").

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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 assisting with the admission of a client who has varicella zoster. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

Correct Answer is A

Explanation

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