A hospitalized client uses a transdermal fentanyl (Duragesic) patch for chronic pain. What action by the nurse is most important for client safety?
a. Assess and record the client's pain every 4 hours.
b. Ensure the client is eating a high-fiber diet.
c. Monitor the client's bowel function every shift.
d. Remove the old patch when applying the new one.
ANS: D
The old fentanyl patch should be removed when applying a new patch so that accidental overdose does not occur. The other actions are appropriate, but not as important for safety.
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A client has undergone a percutaneous stereotactic rhizotomy. What instruction by the nurse is most important on discharge from the ambulatory surgical center?
a. "Avoid having teeth pulled for 1 year." b. "Brush your teeth with a soft toothbrush." c. "Do not use harsh chemicals on your face." d. "Inform your dentist of this procedure."
The purpose of advanced directives is:
1. to give guidance to the person who has durable power of attorney. 2. to give caregivers authority to allow a patient to die with dignity. 3. to allow an individual to instruct caregivers prior to surgery what their wishes are about end-of-life decisions. 4. All of the above are correct.
The nurse writes an intervention for the goal: Patient will sleep for 5 hours uninterrupted each night. The best nursing intervention is:
a. medicate with sedative each night. b. offer warm fluids frequently. c. arrange for a large meal at supper. d. discourage daytime napping.
Which activity plan would best conserve a client's energy without compromising the client's physical or mental health?
A. Reducing hygiene activities and restricting visitors B. Ensuring that the client toilets before and after any other planned activity C. Scheduling energy-intensive activities at the time of day when the client has higher energy levels D. Scheduling as many activities as possible within a small block of time to allow the client a longer, uninterrupted rest period