A nurse has been administering mucolytic-like Hypertonic Nasal drops to an infant she has been caring for. How can she chart the effectiveness of this medication in her narrative note?
The infant tolerated the instillation of the nose drops without any shortness of breath or fever.
Saline nose drops inserted Infant cried a small amount
The infant tolerated the insertion of saline nose drops well
Saline nose drops were inserted into both nares.
Large random breath respirations 26/minute.
Correct Answer : A,C,D
"The infant's nasal congestion appeared to improve following the administration of hypertonic nasal drops. The infant tolerated the insertion of saline nose drops well, with no signs of distress or adverse reactions. The nasal passages appeared clearer after the instillation, and the infant's breathing appeared less congested. There was no significant increase in respiratory rate or other signs of respiratory distress observed. The intervention seemed to have a positive effect on the infant's nasal congestion."
This statement indicates that the mucolytic medication (hypertonic nasal drops) was administered and had a positive effect on the infant's nasal congestion. It also mentions that the infant tolerated the procedure well without any adverse reactions, such as shortness of breath or fever. The absence of distress or adverse symptoms and the observed improvement in nasal congestion indicate the effectiveness of the medication in the nurse's narrative note. The additional information about the saline nose drops and respiratory rate may not directly address the effectiveness of the mucolytic medication and can be documented separately if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Acetaminophen is a commonly used over-the-counter pain reliever and fever reducer. One of the potential adverse reactions to acetaminophen is liver toxicity, which can present with symptoms such as jaundice (yellowing of the skin and eyes), dark urine, and pale stools. It is important for the client to be aware of these signs and symptoms and report them to their healthcare provider if they occur. Monitoring for jaundice can help identify any potential liver-related complications associated with acetaminophen use.
The other options provided in the question are not typically associated with acetaminophen use:
- Tinnitus: Tinnitus refers to a perception of ringing or buzzing in the ears. It is not a commonly reported adverse reaction to acetaminophen.
- Hyperglycemia: Hyperglycemia refers to high blood sugar levels. Acetaminophen does not typically cause hyperglycemia as a side effect.
- Muscle pain: Acetaminophen is used to relieve mild to moderate pain, including muscle pain. It is not an adverse reaction to the medication.
Correct Answer is D
Explanation
Albuterol is a short-acting beta-agonist bronchodilator, commonly used as a rescue medication for acute asthma symptoms. It works quickly to open up the airways and relieve bronchospasm, helping to alleviate the symptoms of an asthma attack. Beclomethasone, formoterol, and salmeterol are long-acting medications used for maintenance therapy in asthma management, not for immediate relief during an acute attack.
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