,The nurse is caring for a client on hospice who was started on a 25 mcg/hr Fentanyl patch
yesterday at 0800. The nurse completes an assessment today at 2000 and reviews the
following assessment data:
Yesterday 0800
BP 98/60
HR 110
RR 24
O2SAT 94%
PAIN 6/10
INTERVENTIONS
Fentanyl patch 25mcg/hr applied
Yesterday 2000
100/55
100
20
95%
2/10
Reposition, visiting with family
Today 0800
92/40
104
24
92%
4/10
Ice pack applied
Today 2000
100/65
110
24
, 94%
7/10
Which intervention is best for the nurse to provide?
a. explain that the fentanyl patch takes time to become effective, and they should
experience relief soon.
b. offer to administer 5mg of morphine orally as prescribed for breakthrough pain
c. reposition the client and offer to give a back rub.
d. call the provider to provide an update on the client's condition - CORRECT ANSWERS
-b. offer to administer 5mg of morphine orally as prescribed for breakthrough pain
Rationale:
A fentanyl patch is effective for 72 hours before it needs to be replaced. This breakthrough
pain is evidenced by a decline in pain rating followed by an elevated pain rating during
the time that the fentanyl patch should still be effective.
When changing a client's post-op wound dressing, the nurse notes yellow purulent
drainage. What action should the nurse take?
a. Notify the healthcare provider.
b. Cover the wound with clean gauze and secure.
c. Irrigate the wound with sterile water and leave open to air.
d. Irrigate the wound with normal saline and pack with gauze. - CORRECT ANSWERS -
a. Notify the healthcare provider.
Rationale:
Yellow purulent drainage is an indication of an infection. This finding should be reported
to the healthcare provider for assessment and intervention.
Choices B, C, and D are all incorrect because the priority action is to notify the healthcare
provider of the status of the wound. Further wound management (cultures, irrigation, or
no irrigation, packing or no packing, antibiotics, etc.) should be determined after
assessment of the site by the surgical team. Irrigating the wound before assessment has
been completed may interfere with medical decision-making and hsould be avoided.
The healthcare provider prescribes enteral feeds of Jevity 1.2 cal at 66mL/hour over 20
hours, and free water flushes of 225 mL q 4 hours x 24 hr via nasogastric tube. How many
mL of total fluid will the client receive in 24 hours? (Enter numerical value only. If rounding
is required, round to one decimal place.) - CORRECT ANSWERS -2670 mL
Rationale:
66mL/hour x 20 hours = 1320 mL
Then it is necessary to calculate the amount of fluid from the free water flushes.
yesterday at 0800. The nurse completes an assessment today at 2000 and reviews the
following assessment data:
Yesterday 0800
BP 98/60
HR 110
RR 24
O2SAT 94%
PAIN 6/10
INTERVENTIONS
Fentanyl patch 25mcg/hr applied
Yesterday 2000
100/55
100
20
95%
2/10
Reposition, visiting with family
Today 0800
92/40
104
24
92%
4/10
Ice pack applied
Today 2000
100/65
110
24
, 94%
7/10
Which intervention is best for the nurse to provide?
a. explain that the fentanyl patch takes time to become effective, and they should
experience relief soon.
b. offer to administer 5mg of morphine orally as prescribed for breakthrough pain
c. reposition the client and offer to give a back rub.
d. call the provider to provide an update on the client's condition - CORRECT ANSWERS
-b. offer to administer 5mg of morphine orally as prescribed for breakthrough pain
Rationale:
A fentanyl patch is effective for 72 hours before it needs to be replaced. This breakthrough
pain is evidenced by a decline in pain rating followed by an elevated pain rating during
the time that the fentanyl patch should still be effective.
When changing a client's post-op wound dressing, the nurse notes yellow purulent
drainage. What action should the nurse take?
a. Notify the healthcare provider.
b. Cover the wound with clean gauze and secure.
c. Irrigate the wound with sterile water and leave open to air.
d. Irrigate the wound with normal saline and pack with gauze. - CORRECT ANSWERS -
a. Notify the healthcare provider.
Rationale:
Yellow purulent drainage is an indication of an infection. This finding should be reported
to the healthcare provider for assessment and intervention.
Choices B, C, and D are all incorrect because the priority action is to notify the healthcare
provider of the status of the wound. Further wound management (cultures, irrigation, or
no irrigation, packing or no packing, antibiotics, etc.) should be determined after
assessment of the site by the surgical team. Irrigating the wound before assessment has
been completed may interfere with medical decision-making and hsould be avoided.
The healthcare provider prescribes enteral feeds of Jevity 1.2 cal at 66mL/hour over 20
hours, and free water flushes of 225 mL q 4 hours x 24 hr via nasogastric tube. How many
mL of total fluid will the client receive in 24 hours? (Enter numerical value only. If rounding
is required, round to one decimal place.) - CORRECT ANSWERS -2670 mL
Rationale:
66mL/hour x 20 hours = 1320 mL
Then it is necessary to calculate the amount of fluid from the free water flushes.
