When preparing to apply a scheduled fentanyl transdermal patch, the nurse notes that the previously applied patch is intact on the client’s upper back and the client denies pain. Which action should the nurse take?

Place the patch on the client’s shoulder and leave both patches in place for 12 hours.

Remove the patch and consult with the healthcare provider about the client’s pain resolution.

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.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Placing the new patch on the client’s shoulder and leaving both patches in place for 12 hours is not recommended. Fentanyl patches are designed to be used one at a time, and overlapping patches can lead to an overdose due to excessive absorption of the medication1. The standard practice is to remove the old patch before applying a new one.

Choice B reason:

Removing the patch and consulting with the healthcare provider about the client’s pain resolution is a cautious approach. However, it is not necessary to consult the healthcare provider if the client denies pain and the patch is due for replacement. The nurse should follow the standard protocol for patch replacement.

Choice C reason:

Applying the new patch in a different location after removing the original patch is the correct action. This ensures that the medication is delivered effectively while preventing skin irritation and potential overdose. The new patch should be placed on a different area of intact skin to allow the previous site to recover.

Choice D reason:

Administering an oral analgesic and evaluating its effectiveness before applying the new patch is not appropriate in this scenario. The client is already receiving pain management through the transdermal patch, and additional oral analgesics are not necessary unless there is breakthrough pain. The focus should be on proper patch replacement

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Correct Answer is D

Explanation

Choice A reason: A complete blood count (CBC) is not typically required before starting statin therapy. While a CBC can provide valuable information about a patient’s overall health, it does not specifically relate to the potential side effects or necessary monitoring for statin use. Statins primarily affect the liver, so monitoring liver function is more critical.

Choice B reason: Serum electrolytes are important for assessing overall metabolic and kidney function, but they are not directly related to the initiation of statin therapy. Statins do not typically affect electrolyte levels, so this test is not necessary before starting the medication.

Choice C reason: Capillary blood glucose levels are important for monitoring diabetes and blood sugar control. While statins can have an impact on blood glucose levels, this is not the primary concern when initiating therapy. Monitoring liver function is more directly related to the potential side effects of statins.

Choice D reason: Serum liver enzymes are crucial to review before starting statin therapy. Statins can cause liver enzyme elevations, indicating liver damage or dysfunction. Therefore, baseline liver enzyme levels should be obtained to monitor for any potential hepatotoxicity during treatment.

A. Administer a PRN dose of an antianxiety drug. B. Obtain orthostatic blood pressure readings. C. Notify the healthcare provider. D. Collect a capillary glucose level.

Correct Answer is C

Explanation

Choice A reason:

Administering a PRN dose of an antianxiety drug might seem like a reasonable action if the tremors are related to anxiety. However, without a clear indication that anxiety is the cause of the tremors, this action could mask the underlying issue and delay appropriate treatment. It is essential to identify the root cause of the tremors before administering any medication.

Choice B reason:

Obtaining orthostatic blood pressure readings is a useful assessment for determining if the client has orthostatic hypotension, which can cause dizziness and fainting. However, this action is not directly related to the complaint of hand tremors. While it is a good practice to monitor vital signs, it does not address the immediate concern of tremors caused by pregabalin.

Choice C reason:

Notifying the healthcare provider is the most appropriate action. Tremors can be a side effect of pregabalin12. The healthcare provider needs to be informed to evaluate the severity of the side effect and decide whether to adjust the medication dosage or switch to an alternative treatment. This ensures that the client receives the most appropriate care and avoids potential complications.

Choice D reason:

Collecting a capillary glucose level is important for clients with diabetes or those at risk of hypoglycemia or hyperglycemia. However, there is no indication in the scenario that the client has diabetes or that blood glucose levels are related to the tremors. Therefore, this action is not directly relevant to the client’s current complaint.

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When preparing to apply a scheduled fentanyl transdermal patch, the nurse notes that the previously applied patch is intact on the client’s upper back and the client denies pain. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which laboratory value should the nurse review prior to administering the initial dose of a statin medication?

Correct Answer is D

Explanation

A client who is receiving pregabalin for fibromyalgia complains of tremors in the hands. Which action should the nurse implement?

Correct Answer is C

Explanation

A client with a history of anaphylactic reaction to penicillin receives a prescription for cephalexin 500 mg PO twice daily. Which action should the nurse take?

When preparing to apply a scheduled fentanyl transdermal patch, the nurse notes that the previously applied patch is intact on the client’s upper back and the client denies pain. Which action should the nurse take?

A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client’s history requires follow-up by the nurse?

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A client is receiving miotics for the treatment of open-angle glaucoma. The nurse determines that a priority nursing problem is the risk for injury. This nursing problem is based on which etiology?

When administering zolpidem to an older client, which computer documentation indicates that the desired outcome has been achieved?

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