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A nurse is reinforcing teaching with a client who has a new prescription for a fentanyl patch. Which of the following instructions should the nurse include?
- A. Apply the patch to the same site each time.
- B. Remove the patch after 24 hours.
- C. Apply the patch to broken skin.
- D. Dispose of the patch in a sharps container.
Correct Answer: D
Rationale: Disposing of the fentanyl patch in a sharps container or per facility protocol prevents accidental exposure to the potent opioid.
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A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?
- A. Anaphylactic
- B. Acute hemolytic
- C. Febrile
- D. Circulatory overload
Correct Answer: A
Rationale: An anaphylactic reaction is correct. Symptoms such as urticaria (hives) and wheezing indicate a severe allergic reaction, which can progress to anaphylaxis. This reaction is caused by a hypersensitivity to plasma proteins in the transfused blood and requires immediate intervention, including stopping the transfusion and administering epinephrine.
A nurse is caring for a client who has a new prescription for tamsulosin. Which of the following adverse effects should the nurse monitor for?
- A. Orthostatic hypotension
- B. Weight gain
- C. Hyperglycemia
- D. Tinnitus
Correct Answer: A
Rationale: Tamsulosin, an alpha-blocker, can cause orthostatic hypotension due to vasodilation, especially with the first dose.
A nurse is caring for a client who has a new prescription for furosemide. Which of the following laboratory values should the nurse monitor?
- A. Potassium
- B. Hemoglobin
- C. Cholesterol
- D. Albumin
Correct Answer: A
Rationale: Furosemide, a loop diuretic, can cause hypokalemia, so monitoring potassium levels is essential to prevent complications like arrhythmias.
A nurse is caring for a client who has a new prescription for sumatriptan. Which of the following adverse effects should the nurse monitor for?
- A. Chest pain
- B. Weight loss
- C. Bradycardia
- D. Hypoglycemia
Correct Answer: A
Rationale: Sumatriptan, a triptan, can cause chest pain or tightness, which may indicate vasoconstriction and requires monitoring.
A nurse is caring for a client who has a new diagnosis of pancreatitis. Which of the following findings should the nurse expect?
- A. Epigastric pain
- B. Weight gain
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: Epigastric pain is a hallmark symptom of pancreatitis due to inflammation of the pancreas.