Question

The nurse is visiting a client at home with intractable cancer pain. The client has a transdermal fentanyl patch on her right chest area. It is most important for the nurse to

A. ) Instruct the client to note fatigue or extreme sleepiness.

B. ) Inform the client about use of alcohol with fentanyl.

C. ) Assess for the date of the client's last bowel movement.

D. ) Remove the heating pad present on the chest area

Answer 1

Option D, remove the heating pad present on the chest area

Step-by-step explanation:

When the patient is receiving pharmacotherapeutic treatment via a fentanyl transdermal patch, the nurse wants to monitor two things: central nervous system (CNS) depression and overdose. Both can be a problem for the patient's well being, however, the most important aspect of their care would be which of these two things has the potential to pose the most immediate threat. In this case, the most important aspect is preventing overdose by removing the heating pad present on the patient's chest. Concurrent use of the transdermal patch and heating pad can increase the rate at which the medication is released which, in turn, can increase the risk of the patient experiencing an overdose. Because the patient is currently wearing the pad, it poses the most immediate threat.

Why Not the Other Answers?:
The nurse should include informing the patient not to use alcohol or other CNS depressant medications with the fentanyl because it could cause sedation (possibly coma) and respiratory depression both of which can be fatal problems. However, unless the patient is current taking this medications (e.g. benzodiazepines) or drinking alcohol, the information is not as pertinent as removing the heating pad.

Constipation is a common side effect of fentanyl administration, therefore the nurse should also assess the patient for their last bowel movement (BM) however this is not an immediate threat to the patient's wellbeing and can be treated with added bulk, increased fluids, and possibly laxative medications.

Fatigue and extreme sleepiness or drowsiness are expected side effects of CNS depressant medications. Again, the nurse would want to include this in their patient teaching because the patient could place themselves or others in danger if they take the medication and drive or operate heavy machinery. However, it is not the most important aspect to monitor because if they are currently in the nurse's care, they are likely not driving or operating heavy machinery.