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 C

Explanation

A. Consume foods that are high in iodine: While iodine is necessary for thyroid function, levothyroxine therapy is aimed at directly replacing thyroid hormone. Excessive iodine intake can potentially disrupt thyroid hormone balance, so encouraging high iodine consumption is not the primary focus when educating about levothyroxine use.

B. Administer levothyroxine at bed time: Levothyroxine is best absorbed when taken in the morning on an empty stomach, ideally 30 to 60 minutes before breakfast. Taking it at bedtime could reduce its absorption if the stomach is not empty or if it interacts with food or other nighttime medications.

C. Take medication on an empty stomach: Levothyroxine absorption is significantly improved when the medication is taken on an empty stomach, separated from food and other medications by at least 30 to 60 minutes. This practice ensures optimal therapeutic effects and maintains stable thyroid hormone levels.

D. Avoid the use of iron supplements: While iron supplements can interfere with the absorption of levothyroxine, the instruction is not necessarily to avoid them altogether, but rather to separate their administration by several hours (usually 4 hours) from the levothyroxine dose to ensure proper absorption of both.

A. Advise the client that once symptoms occur it is too late to receive an influenza vaccination. B. Explain to the client that antibiotics are not useful in treating viral infections such as influenza. C. Refer the client to the healthcare provider at the clinic to obtain a medication prescription. D. Instruct the client that over-the-counter medications are sufficient to manage influenza symptoms.

Correct Answer is C

Explanation

A. Advise the client that once symptoms occur it is too late to receive an influenza vaccination: While it is true that vaccination is preventive and not therapeutic, the client's question concerns treatment, not vaccination. Discussing vaccination at this point does not directly address the immediate need for antiviral therapy.

B. Explain to the client that antibiotics are not useful in treating viral infections such as influenza: Although educating about antibiotic misuse is important, this response does not answer the client’s question about oseltamivir, which is an antiviral medication specifically intended for early influenza treatment.

C. Refer the client to the healthcare provider at the clinic to obtain a medication prescription: Oseltamivir must be prescribed and is most effective when started within 48 hours of symptom onset. Prompt referral ensures the client can receive the medication in time to potentially shorten the illness and reduce complications.

D. Instruct the client that over-the-counter medications are sufficient to manage influenza symptoms: Over-the-counter remedies may relieve symptoms, but they do not treat the viral infection. Early antiviral treatment with oseltamivir can decrease the severity and duration of influenza, particularly in high-risk individuals.

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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 client receives a new prescription for levothyroxine. Which statement made by the client indicates to the nurse education was effective?

Correct Answer is C

Explanation

A client with symptoms of influenza that started the previous day asks the clinic nurse about taking oseltamivir to treat the infection. Which response should the nurse provide?

Correct Answer is C

Explanation

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