A nurse is reinforcing teaching with a client about using transdermal patches at home. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
“I will clean and dry the area before applying the patch."
“I will use lotion on irritated skin before applying a new patch in that area."
“I will remove the old patch and apply a new one in the same location."
“I will press the patch securely in place on my forearm."
The Correct Answer is A
A. Cleaning and drying the area before applying the patch is essential to ensure proper adhesion and effectiveness of the medication. This statement indicates the client understands proper application procedures.
B. Using lotion on irritated skin before applying a new patch can interfere with the patch's ability to adhere and may affect medication absorption. Therefore, this statement indicates a lack of understanding.
C. Removing the old patch and applying a new one in the same location is generally not recommended because it can lead to skin irritation and decreased absorption. This indicates a misunderstanding of proper patch rotation.
D. While pressing the patch securely is important, it is not as critical as ensuring the skin is clean and dry before application. Thus, this statement alone does not indicate full understanding of the teaching.
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Correct Answer is C
Explanation
A. Checking residual volume is important for assessing tolerance to feedings, but it is not the priority action to prevent complications related to decreased consciousness.
B. Observing the client’s respiratory status is crucial but not the priority action related to enteral feedings.
C. Elevating the head of the client's bed 30° to 45° is the priority action, as it reduces the risk of aspiration during enteral feeding, which is a significant concern for clients with decreased consciousness.
D. Monitoring intake and output is important for overall assessment but is not the immediate priority in this context.
Correct Answer is B
Explanation
A. Observing the client is inappropriate as they are demonstrating signs of choking and require immediate intervention.
B. Performing the Heimlich maneuver is appropriate as the guest is unable to talk, which indicates a potential airway obstruction that needs to be relieved promptly.
C. Slapping the client on the back may not be effective and could worsen the obstruction, especially since they are grasping their throat.
D. Assisting the client to the floor and beginning mouth-to-mouth resuscitation is not appropriate in this situation, as the priority is to clear the obstruction, not to provide rescue breaths.