Nokea
The charge nurse is observing the new graduate administering a fentanyl (Duragesic) patch to a client diagnosed with cancer. Which action by the new graduate requires intervention by the charge nurse?
- A. The new graduate documents the date and time on the patch.
- B. The new graduate removes the patch 24 hours after it is placed on the client.
- C. The new graduate rotates the application site on the client's body.
- D. The new graduate checks the client's name band and date of birth.
Correct Answer: B
Rationale: Fentanyl patches last 72 hours; removing at 24 hours is incorrect and requires intervention. Dating, rotating sites, and ID checks are correct.
You may also like to solve these questions
The client admitted with pneumonia is taking Imuran, an immunosuppressive agent. Which question should the nurse ask the client regarding this medication?
- A. Do you know this medication has to be tapered off when discontinued?
- B. Have you been exposed to viral hepatitis B or C recently?
- C. Why are you taking this medication, and how long have you taken it?
- D. Do you have a lot of allergies or sensitivities to different medications?
Correct Answer: C
Rationale: Imuran (azathioprine) use and duration clarify indication (e.g., autoimmune) and infection risk, critical with pneumonia. Tapering, hepatitis, or allergies are less immediate.
To which client would the nurse question administering the osmotic diuretic mannitol (Osmitrol)?
- A. The client with 4+ pitting pedal edema.
- B. The client with decorticate posturing.
- C. The client with widening pulse pressure.
- D. The client with a positive doll's eye test.
Correct Answer: C
Rationale: Widening pulse pressure suggests increased intracranial pressure, a contraindication for mannitol due to potential brain herniation. Edema or neurological signs are indications.
A 68-year-old client was admitted with congestive heart failure, has been digitalized, and is now taking a maintenance dose of digoxin 0.25 mg PO daily. The client is to be discharged soon. Which assessment is of most immediate concern to the nurse?
- A. The client's apical pulse is 66.
- B. The client says that he is nauseous and has no appetite.
- C. The client says that he will take his pill every morning.
- D. The client has lost 8 lb since his admission one week ago.
Correct Answer: B
Rationale: Nausea and anorexia are signs of digoxin toxicity, requiring immediate attention to prevent serious complications.
A client with anemia has a new prescription for ferrous sulfate. In teaching the client about diet and iron supplements, the nurse should emphasize that absorption of iron is enhanced if taken with which substance?
- A. Acetaminophen
- B. Orange juice
- C. Low fat milk
- D. An antacid
Correct Answer: B
Rationale: Orange juice. Ascorbic acid enhances the absorption of iron.
The client diagnosed with bipolar disorder has been taking valproic acid (Depakote), an anticonvulsant, for four (4) months. Which assessment data would warrant the medication being discontinued?
- A. The client's eyes are yellow.
- B. The client has mood swings.
- C. The client's BP is 164/94.
- D. The client's serum level is 75 mcg/mL.
Correct Answer: A
Rationale: Yellow eyes suggest hepatotoxicity, a serious valproic acid side effect, warranting discontinuation. Mood swings, hypertension, or normal levels are less critical.