patient refused a newly open fentanyl patch which of the following actions should the nurse take patient refused a newly open fentanyl patch which of the following actions should the nurse take
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Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam 2023

1. A patient refused a newly open fentanyl patch. Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct action for the nurse to take when a patient refuses a newly open fentanyl patch is to ask another nurse to witness the disposal of the new patch. This is essential for accountability and ensuring proper disposal procedures are followed. Choice B is incorrect because disposing of the patch in a sharps container without a witness does not ensure proper accountability. Choice C is incorrect as sending the patch back to the pharmacy is not the appropriate action for disposal. Choice D is incorrect because although documenting the refusal is important, it is also crucial to ensure proper disposal of the unused patch by having another nurse witness it.

2. A client receiving chemotherapy reports nausea and vomiting. Which of the following medications should the nurse anticipate administering?

Correct answer: A

Rationale: The correct answer is A: Ondansetron. Ondansetron is a commonly used antiemetic for managing nausea and vomiting in clients undergoing chemotherapy. It works by blocking serotonin to reduce these symptoms effectively. Metoclopramide (choice B) is another antiemetic but is more commonly used for gastric motility disorders. Promethazine (choice C) is an antihistamine with antiemetic properties, but ondansetron is often preferred for chemotherapy-induced nausea and vomiting due to its efficacy and fewer side effects. Lorazepam (choice D) is a benzodiazepine used for anxiety and insomnia, not typically for managing nausea and vomiting in this context.

3. A male patient is receiving testosterone therapy for hypogonadism. What serious adverse effect should the nurse monitor for during this therapy?

Correct answer: A

Rationale: The correct answer is A: Increased risk of liver dysfunction. Testosterone therapy can lead to liver dysfunction, including cholestatic jaundice and hepatitis. This adverse effect necessitates monitoring of liver function tests during testosterone therapy. Choice B, increased risk of prostate cancer, is incorrect because testosterone therapy does not cause prostate cancer but is contraindicated in patients with known or suspected prostate cancer. Choice C, increased risk of bone fractures, is incorrect as testosterone therapy is actually associated with an increase in bone mineral density, reducing the risk of fractures. Choice D, increased risk of breast cancer, is incorrect because testosterone therapy in males does not increase the risk of breast cancer.

4. Maggie, a child in protective custody, is found to have an imaginary friend, Holly. Her foster family shares this information with the nurse. The nurse teaches the family members about children who have suffered trauma and knows her teaching was effective when the foster mother states:

Correct answer: C

Rationale: Imaginary friends can serve as a coping mechanism for children, especially those who have experienced trauma. They can provide comfort and a sense of control in challenging situations. Acknowledging and supporting the child's imaginary friend can be beneficial in their emotional healing and development.

5. A nurse is providing dietary teaching to a client who has a body mass index of 28. Which of the following actions should the nurse take?

Correct answer: D

Rationale: Referring the client to a weight-loss support group can provide the necessary support and motivation to achieve weight loss goals.

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