A nurse is preparing to administer fentanyl 100 mcg via IV bolus to a client who is postoperative and is currently receiving 0.9% sodium chloride by continuous IV infusion. Which of the following actions should the nurse take?

Flush the port with heparin prior to administering the medication.

Inject the medication into the port closest to the client.

Pinch the tubing below the injection port prior to administration.

Administer the medication over 10 seconds.

Answer and Explanation

The Correct Answer is B

A. Flush the port with heparin prior to administering the medication. Heparin is not typically used to flush the port before administering IV medications; saline is generally used for flushing.
B. Inject the medication into the port closest to the client. This ensures the medication is delivered quickly and effectively, minimizing dilution and maximizing its effect.
C. Pinch the tubing below the injection port prior to administration. Pinching the tubing can help ensure the medication goes into the client quickly but should be done only if specified by protocol.
D. Administer the medication over 10 seconds. Fentanyl should be administered slowly over 1-2 minutes to prevent rapid administration-related side effects like hypotension or respiratory depression.

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Correct Answer is D

Explanation

A. "The provider should sign the advance directives before it is valid." This statement is incorrect. Advance directives are valid once they are signed by the client, not the provider. The provider's signature is not required.
B. "The health care proxy is required to approve the client's wishes listed in advance directives." This statement is incorrect. The health care proxy does not have the authority to approve or alter the client's wishes. The proxy is responsible for ensuring that the client's wishes are followed as documented in the advance directives.
C. "The health care proxy can add additional treatments to the advance directives." This statement is incorrect. The health care proxy cannot add or change treatments listed in the advance directives. Their role is to make decisions based on the existing directives.
D. "Advance directives should be documented in the client's medical record." This statement is correct. Advance directives should be documented in the client's medical record to ensure that all healthcare providers are aware of and can adhere to the client's wishes.

A. The client uses religious symbols to relieve pain. B. The client requests holy communion daily. C. The client refuses medical treatment on holy days. D. The client prefers a female nurse to provide care.

Correct Answer is D

Explanation

A. The client uses religious symbols to relieve pain. This is not a typical practice in Islam.
B. The client requests holy communion daily. Holy communion is a Christian practice, not an Islamic one.
C. The client refuses medical treatment on holy days. There are no specific prohibitions against receiving medical treatment on holy days in Islam.
D. The client prefers a female nurse to provide care. Many Muslim women prefer to be cared for by female healthcare providers due to modesty and religious practices.

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A nurse is preparing to administer fentanyl 100 mcg via IV bolus to a client who is postoperative and is currently receiving 0.9% sodium chloride by continuous IV infusion. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is providing an in-service for a group of staff nurses about advance directives. Which of the following statements by a staff nurse indicates the teaching was effective?

Correct Answer is D

Explanation

A nurse is caring for a female client who practices Islam. Which of the following client preferences should the nurse expect when providing care?

Correct Answer is D

Explanation

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