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 ["B","D","E"]

Explanation

A. Antiproliferative agents: These are primarily used in conditions like organ transplantation and autoimmune diseases to suppress cell growth. They are not indicated for the management of asthma and would not benefit the client’s respiratory symptoms.

B. Biologics: Biologics such as omalizumab (anti-IgE) or mepolizumab (anti-IL-5) are used in moderate to severe asthma cases that are not well controlled with inhaled therapies. They target specific pathways in the inflammatory process and can help reduce exacerbations in allergic or eosinophilic asthma.

C. Loop diuretic: Loop diuretics like furosemide are used to manage fluid overload in conditions like heart failure, not for airway inflammation or bronchospasm in asthma. They have no direct role in asthma management.

D. Glucocorticoids: Inhaled or systemic glucocorticoids are essential in controlling airway inflammation and preventing exacerbations in asthma. They are a cornerstone of asthma management, especially if frequent rescue inhaler use is noted.

E. Long-acting beta agonists (LABAs): LABAs like salmeterol or formoterol are used in combination with inhaled corticosteroids for maintenance therapy in moderate to severe asthma. They help provide sustained bronchodilation but are not used alone due to increased risk of asthma-related death if unpaired with a steroid.

F. Angiotensin-converting enzyme (ACE) inhibitor: ACE inhibitors are primarily used for hypertension and heart failure. They are not asthma treatments and can sometimes worsen coughing, which could complicate asthma symptoms.

A. Dry mouth, blurred vision, and constipation. B. Headache, jaundice, and diarrhea. C. Bradycardia, delirium, and sedation. D. Insomnia, hypertension, and vomiting.

Correct Answer is A

Explanation

A. Dry mouth, blurred vision, and constipation: These symptoms are classic anticholinergic side effects associated with many antidepressants, especially tricyclic antidepressants (TCAs). They result from the blockade of muscarinic receptors and are frequently reported by clients receiving these medications.

B. Headache, jaundice, and diarrhea: While headaches can occur with antidepressant use, jaundice is rare and would suggest serious liver toxicity rather than a common side effect. Diarrhea may happen with selective serotonin reuptake inhibitors (SSRIs) but is less typical overall than anticholinergic symptoms.

C. Bradycardia, delirium, and sedation: Some antidepressants can cause sedation, but bradycardia and delirium are not common side effects across the entire antidepressant class. These would be more likely associated with toxicity or drug interactions rather than typical daily use.

D. Insomnia, hypertension, and vomiting: Insomnia can occur with certain antidepressants like SSRIs or SNRIs, but hypertension and vomiting are less consistently seen across all antidepressant classes. These symptoms are not considered the hallmark side effects of antidepressant therapy.

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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?

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