A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take?
Apply the patch within 1 hr of removing it from the protective pouch.
Shave hairy areas of skin prior to application.
Wear gloves to apply the patch to the client's skin.
Remove the previous patch and place it in a tissue.
The Correct Answer is C
A. Transdermal nicotine patches should be applied immediately after removal from the protective pouch, but waiting for up to 1 hour is acceptable according to most manufacturers' instructions.
B. Shaving hairy areas of skin is not necessary prior to applying a transdermal nicotine patch and may cause skin irritation.
C. Wearing gloves during the application of the transdermal nicotine patch helps to prevent nicotine absorption through the nurse's skin and reduces the risk of accidental exposure.
D. The nurse should properly dispose of the previous patch according to facility protocols rather than placing it in a tissue, as used nicotine patches can still contain active medication and pose a risk of exposure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Negligence refers to the failure to provide care that a reasonably prudent person would have under similar circumstances, resulting in harm to the patient.
B. Battery involves the intentional harmful or offensive contact with a person without their consent. While similar to assault, battery involves actual physical contact, such as forcibly inserting a urinary catheter without consent.
C. Assault occurs when a threat of harmful or offensive contact is made, causing fear or apprehension in the victim. In this scenario, the newly licensed nurse's statement of
inserting a urinary catheter without consent if the client does not void constitutes an act of assault.
D. Libel involves making defamatory statements in written or published form, which is not applicable in this scenario.
Correct Answer is ["B","C","E","G","H"]
Explanation
A. Nausea, while uncomfortable, is a common symptom during pregnancy and should be addressed, but it is not as urgent as the other symptoms in this context.
B. The deep tendon reflex (DTR) being 3+ bilaterally indicates hyperreflexia, which can be associated with conditions like preeclampsia, hence the need for follow-up.
C. The elevated blood pressure reading of 148/94 mm Hg is indicative of hypertension, which could be a sign of preeclampsia, a serious pregnancy complication.
D. The fetal heart tracing, while important, does not show immediate concern with a rate of 140/min, which is within normal limits.
E. The weight gain of 0.68 kg (1.5 lb) within the last week is significant and could be indicative of fluid retention, which is concerning in the context of the client's other symptoms.
F. The respiratory rate of 20/min falls within the normal range, and there are no other indications of respiratory distress or abnormalities in the assessment findings provided. Therefore, respiratory assessment is not a priority for follow-up at this time.
G. The fundal height measurement of 29 cm is appropriate for 30 weeks of gestation, but given the other symptoms, it should be monitored for any rapid changes.
H. The presence of 1+ dependent edema noted bilaterally suggests fluid retention, which is a concerning finding and warrants further assessment to evaluate for signs of preeclampsia or other complications.
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