The nurse is preparing to apply the client’s scheduled fentanyl transdermal patch. The nurse notes the previously applied patch is intact on the client’s upper back and the client reports no pain. Which action should the nurse take?
Remove the patch and consult with the healthcare provider about the client’s pain resolution.
Place the patch on the client’s shoulder and leave both patches in place for 12 hours.
Apply the new patch in a different location after removing the original patch.
Administer an oral analgesic and evaluate its effectiveness before applying the new patch.
The Correct Answer is C
A) Remove the patch and consult with the healthcare provider about the client’s pain resolution: While it’s essential to assess the need for continued pain management, removing the patch without replacing it could lead to inadequate pain control, especially if the client still requires opioid analgesia. Additionally, fentanyl patches are typically left in place for their prescribed duration, and removing them prematurely could disrupt the pain management plan.
B) Place the patch on the client's sh’ulder and leave both patches in place for 12 hours: Applying a new patch without removing the previous one could result in a higher-than-intended dose of fentanyl, increasing the risk of opioid toxicity. Leaving both patches in place simultaneously is not recommended.
C) Apply the new patch in a different location after removing the original patch: This is the correct action. Applying the new patch in a different location helps prevent skin irritation and ensures consistent drug absorption. Rotating patch sites according to the manufacturer's in’tructions is important for optimal medication delivery.
D) Administer an oral analgesic and evaluate its effectiveness before applying the new patch: While oral analgesics may provide temporary relief, they may not be as effective as transdermal fentanyl for managing chronic pain, especially if the client has been on a stable regimen of fentanyl patches. Additionally, delaying the application of the new patch could lead to inadequate pain control.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Increased frequency of lacrimation is not typically associated with miotic therapy. Miotics work by constricting the pupil and increasing outflow of aqueous humor to reduce intraocular pressure, but they do not directly affect lacrimation (tear production). Therefore, this option is not the etiology for the “Risk for injury” nursing problem.
B) Decreased night vision is a common side effect of miotic therapy. Miotics constrict the pupil, which can reduce the amount of light entering the eye, leading to impaired night vision or difficulty seeing in low-light conditions. This impaired vision increases the risk of injury, particularly in situations with reduced lighting.
C) Increased sensitivity to light (photophobia) is not typically associated with miotic therapy. Miotics constrict the pupil, which may actually reduce sensitivity to light by decreasing the amount of light entering the eye. Therefore, increased sensitivity to light is not the etiology for the “Risk for injury” nursing problem in this case.
D) Diminished color perception is not a common side effect of miotic therapy. Miotics primarily affect pupil constriction and intraocular pressure but do not typically alter color perception. Therefore, diminished color perception is not the etiology for the “Risk for injury” nursing problem.
Correct Answer is A
Explanation
A) Feverfew may interact with aspirin or nonsteroidal anti-inflammatory drugs: This information is crucial to include in the teaching plan because feverfew has been reported to interact with medications such as aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), potentially increasing the risk of bleeding. Clients need to be aware of potential drug interactions to prevent adverse effects and ensure safe use of feverfew.
B) Those with allergies to chamomile, ragweed, or yarrow should not take feverfew: While this is important information to consider, it may not be as immediately relevant to the client's current situation of experiencing fewer headaches with feverfew use. However, it is still important to assess for allergies and sensitivities to prevent allergic reactions.
C) Increased anxiety and nervousness have been reported by those taking feverfew: Although this is a potential side effect of feverfew, it may not be the most important information to include in the teaching plan for a client who is experiencing fewer headaches with feverfew use. The focus should be on the client's positive response to the herbal remedy and potential interactions with other medications.
D) Abdominal pain, gas, nausea, vomiting, and diarrhea can occur when taking feverfew: While this is important information regarding potential side effects of feverfew, it may not be as immediately relevant to the client's current situation of experiencing fewer headaches with feverfew use. However, clients should be informed about possible adverse effects to monitor for and report to their healthcare provider if they occur.
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