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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Document the assessment findings in the electronic health record: Riluzole is not curative for ALS; it only modestly slows disease progression. Continuing muscle weakness and atrophy are expected findings in ALS, even after starting treatment. Accurate documentation is appropriate because no immediate change in therapy is indicated based solely on these observations.

B. Explain that the medication takes several weeks to reverse symptoms: Riluzole does not reverse ALS symptoms. It may slightly prolong survival by slowing the progression of muscle weakness, but it does not regenerate lost function or reverse disease-related damage.

C. Advise the client to schedule an appointment for liver function tests: Riluzole can affect liver function and periodic monitoring is important, but muscle weakness alone does not directly signal liver problems. Unless there are signs of hepatotoxicity, there is no immediate need for unscheduled testing.

D. Withhold the medication until the healthcare provider is notified: There is no indication to withhold riluzole based on ongoing muscle weakness, as this is consistent with the natural course of ALS. Interrupting therapy without a clear medical reason could harm the client.

A. Promotes excretion of uric acid in the urine. B. Prevents the formation of kidney stones. C. Decreases pain and burning during urination. D. Increases the strength of the urine stream.

Correct Answer is A

Explanation

A. Promotes excretion of uric acid in the urine: Probenecid works by inhibiting the reabsorption of uric acid in the renal tubules, leading to increased urinary excretion of uric acid. This action helps lower serum uric acid levels, making it effective in the management of chronic gout and hyperuricemia.

B. Prevents the formation of kidney stones: Although lowering uric acid levels can indirectly reduce the risk of uric acid kidney stones, probenecid's primary mechanism is to promote uric acid excretion rather than directly preventing stone formation. Additional measures like hydration are typically emphasized for stone prevention.

C. Decreases pain and burning during urination: Pain and burning during urination are usually related to infections or inflammatory processes, not elevated uric acid. Probenecid does not have antimicrobial or analgesic effects and is not used to treat dysuria symptoms.

D. Increases the strength of the urine stream: Weak urine flow is commonly associated with bladder outlet obstruction or prostate issues. Probenecid does not act on the urinary tract muscles or prostate and has no role in improving the strength or flow of urination.

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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

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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