The client is receiving fentanyl transdermal patch 25 mcg/hr. Which nursing intervention is most important for the nurse to initiate?

Observe the client's mucous membranes.

Auscultate the client's bowel sounds.

Assess the client's level of consciousness (LOC).

Record the client's urinary output.

Answer and Explanation

The Correct Answer is C

A. Observe the client's mucous membranes: Monitoring mucous membranes is useful for assessing hydration status, but it is not the most critical intervention related to fentanyl use. The primary concern with opioid administration, especially fentanyl, is central nervous system and respiratory depression.

B. Auscultate the client's bowel sounds: Opioids like fentanyl can cause constipation due to slowed gastrointestinal motility. Although monitoring bowel sounds is important, it is a secondary concern compared to the immediate need to assess neurological and respiratory status.

C. Assess the client's level of consciousness (LOC): Fentanyl, a potent opioid, poses a significant risk for sedation and respiratory depression. Regular assessment of the client's LOC is essential to detect early signs of opioid toxicity, such as excessive drowsiness, confusion, or unresponsiveness, allowing for prompt intervention.

D. Record the client's urinary output: Opioids can lead to urinary retention, making output monitoring necessary, but it is not the most urgent priority. Ensuring the client's neurological status and breathing are stable takes precedence when administering potent opioids like fentanyl.

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Correct Answer is D

Explanation

A. Explain the need to refrain from alcohol use while taking the drug: Although avoiding alcohol is very important when taking clonazepam due to increased central nervous system depression, the client’s current symptoms of slurred speech and ataxia are concerning side effects that must be addressed first through immediate clinical intervention rather than just education.

B. Document the client's continued seizure activity: Slurred speech and ataxia are not typical signs of seizure activity; they are more indicative of central nervous system depression or toxicity from clonazepam. Simply documenting the symptoms without further action could delay critical treatment adjustments.

C. Advise the client to discontinue the medication immediately: Abruptly stopping clonazepam can lead to withdrawal seizures and other serious complications. Medication discontinuation should always be managed carefully under the direction of the healthcare provider to prevent additional risks.

D. Report these side effects to the healthcare provider: Slurred speech and an ataxic gait suggest clonazepam toxicity or overdose. Promptly notifying the healthcare provider allows for dosage adjustment or possible medication change, which is essential to prevent worsening central nervous system depression and maintain patient safety.

A. Calcium 13.0 mg/dL (3.3 mmol/L). B. Magnesium 2.4 mEq/L (2.4 mmol/L). C. Potassium 5.2 mEq/L (5.2 mmol/L). D. Sodium 132 mEq/L (132 mmol/L)

Correct Answer is A

Explanation

A. Calcium 13.0 mg/dL (3.3 mmol/L): Alendronate is used to inhibit bone resorption and is typically prescribed when calcium levels are normal. A high calcium level suggests hypercalcemia, which could worsen if alendronate is given. Therefore, the medication should be withheld, and the healthcare provider must be notified for further evaluation.

B. Magnesium 2.4 mEq/L (2.4 mmol/L): This magnesium level is slightly elevated but is not critically abnormal. Magnesium levels are not a primary consideration when deciding whether to administer alendronate, and this finding alone would not necessitate withholding the medication.

C. Potassium 5.2 mEq/L (5.2 mmol/L): Mild hyperkalemia is noted here, but potassium levels do not directly impact the safety or effectiveness of alendronate. The nurse should monitor it but does not need to withhold alendronate based on this finding.

D. Sodium 132 mEq/L (132 mmol/L): This value indicates mild hyponatremia, but sodium abnormalities are not a direct contraindication to alendronate therapy. The medication could still be administered while addressing the sodium imbalance separately.

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The client is receiving fentanyl transdermal patch 25 mcg/hr. Which nursing intervention is most important for the nurse to initiate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male client with a newly diagnosed seizure disorder starts a prescription for clonazepam. One week later, the nurse observes that his speech is slurred and he has an ataxic gait. Which action should the nurse implement?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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