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 B
Explanation
Codeine is an opioid medication that can cause drowsiness and dizziness. Changing positions quickly, especially from lying down to standing up, can increase the risk of falls or accidents.
Instructing the client to change positions slowly helps prevent orthostatic hypotension (a drop in blood pressure upon standing) and reduces the risk of falls.
The other options listed are not appropriate instructions for a client taking codeine:
A. "You should expect to experience diarrhea while taking this medication." While constipation is a common side effect of opioids, diarrhea is not typically associated with codeine use. Therefore, there is no need to expect or warn about diarrhea as an anticipated effect of taking codeine.
C. "You should limit alcohol intake to 12 ounces daily." Mixing alcohol with codeine can have harmful effects, such as increased sedation and respiratory depression. However, it is generally recommended to avoid alcohol completely while taking codeine, rather than setting a specific limit of 12 ounces daily.
D. "You should take the medication on an empty stomach to prevent nausea." Taking codeine with or without food can vary depending on individual factors and the specific instructions provided by the healthcare provider. However, taking codeine on an empty stomach does not necessarily prevent nausea. In fact, taking it with food may help reduce stomach upset for some individuals. It is best to follow the specific instructions provided by the healthcare provider regarding the timing of codeine administration with or without food.
Correct Answer is C
Explanation
Dimenhydrinate is an antihistamine commonly used to treat motion sickness and vertigo. One of the common side effects of dimenhydrinate is dizziness. It can cause sedation and impair cognitive and motor functions. Therefore, the client should be advised to be cautious when engaging in activities that require alertness, such as driving or operating machinery. Monitoring for dizziness and taking appropriate precautions can help prevent accidents and ensure the client's safety.
The other options provided in the original response are incorrect:
- Administer 24 hr before effects are desired: This is not a correct instruction for dimenhydrinate. The medication is typically taken 30 minutes to 1 hour before the desired effects, such as before travel to prevent motion sickness.
- Expect an increase in salivation: Dimenhydrinate does not typically cause an increase in salivation. This is not a known side effect of the medication.
- Observe for diarrhea: Diarrhea is not a common side effect of dimenhydrinate. While gastrointestinal disturbances can occur with some antihistamines, it is not typically associated with dimenhydrinate use.
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