A patient who is using a fentanyl (Duragesic) patch and immediate-release morphine for chronic cancer pain develops new-onset confusion, dizziness, and a decrease in respiratory rate. Which action should the nurse take first?
a. Obtain vital signs.
b. Remove the fentanyl patch.
c. Notify the health care provider.
d. Administer the prescribed PRN naloxone (Narcan).
ANS: B
The assessment data indicate a possible overdose of opioid. The first action should be to remove the patch. Naloxone administration in a patient who has been chronically using opioids can precipitate withdrawal and would not be the first action. Notification of the health care provider and continued monitoring are also needed, but the patient's data indicate that more rapid action is needed. The respiratory rate alone is an indicator for immediate action before obtaining blood pressure, pulse, and temperature.
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The nurse in the obstetrical clinic is setting appointments for clients seeking preconceptual care. Which client should be seen first?
1. 36-year-old, has never been pregnant, takes medication for a seizure disorder 2. 15-year-old, smokes one pack per day, had a miscarriage four months ago 3. 22-year-old, runs long distances, has been on the pill for six years 4. 29-year-old, has had two abortions, takes a multiple-vitamin supplement
Directions: Apply the guidelines relating to the use of leading and trailing zeros and express the following metric notations correctly. .65 mL
ANS:
What are the three types of passive transport? (Select all that apply.)
a. Diffusion b. Titration c. Osmosis d. Distillation e. Filtration
A nurse is caring for a client with seizure disorders who is admitted to the health care facility. The client is prescribed phenytoin. During therapy, which of the following would be most important for the nurse to include in the ongoing assessment?
A) Check the client's temperature every 3 to 4 hours. B) Obtain serum plasma drug levels regularly. C) Assess the client's respiratory rate. D) Evaluate the client's pulse rate and rhythm.