A client has an order for fentanyl (Sublimaze) prior to surgery. After administering the medication, the nurse should monitor the client for:
1. constipation.
2. tremors.
3. sleepiness.
4. respiratory distress.
Answer: 4
1. The client should not experience constipation after one dose of fentanyl.
2. Tremors are not a side effect of fentanyl.
3. Sleepiness is the expected outcome of giving this medication.
4. Fentanyl causes central nervous system depression, and can cause respiratory distress.
You might also like to view...
A patient is receiving intravenous amphotericin. Which of the following assessments warrants the discontinuation of the antifungal agent?
A) Sodium of 138 mEq/L B) Hematocrit of 39% C) Blood urea nitrogen of 60 mg/dL D) AST 10 Unit/L
The nurse recognizes the signs of ____________________ syndrome in a child in "90-90" traction when the toes are pale and edematous and have a very slow capillary refill
ANS:
The nurse is performing a breast examination and is palpating into the tail of Spence. Why is it appropriate to palpate this area of the breast during an examination?
1. It does not contain any lymph nodes. 2. It can show the difference between fibrocystic disease and fibroadenomas. 3. Breast cancer occurs more frequently in this area. 4. Peau d'orange may occur in this area of the breast.
The nurse is concerned that the chain of custody for evidence collected in the emergency department may have been breached
Which situation would support the nurse's concern? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The evidence was placed at the foot of the patient's bed while the nurse who collected it went to get an evidence bag. 2. The nurse who collected the evidence sealed it in a bag and placed a label on the bag. 3. The nurse who collected the evidence left it at the busy nurses' station for law enforcement authorities to pick up. 4. The nurse handed the sealed and labeled evidence bag to a law enforcement officer. 5. The wet clothing was hung in the utility room to dry before bagging.