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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

During an asthma attack, the primary concern is the patient's ability to breathe and maintain adequate oxygenation. Monitoring the patient's respiratory rate and oxygen saturation (SpO2) with a pulse oximeter provides crucial information about the effectiveness of the albuterol treatment and the patient's respiratory status. It helps determine if the airway is opening up, if oxygen levels are improving, and if the patient is responding positively to the medication.
While determining the time of the patient's last meal can be relevant for certain interventions, it is not the immediate priority during an asthma attack. It is more important to focus on assessing and managing the patient's breathing and oxygenation first.
Monitoring the patient's temperature and blood pressure can be important for a comprehensive assessment, but they are not the immediate priority during an acute asthma attack. Addressing the patient's respiratory distress takes precedence.
Providing education on asthma management and treatment is an important aspect of care, but it should be done after the patient's acute symptoms are addressed and stabilized. In the immediate assessment phase, the focus is on assessing and managing the patient's respiratory status. Education can be provided once the patient's immediate needs are addressed.

A. The client waits 10 min between inhalations. B. The client takes a quick inhalation while releasing the medication from the inhaler. C. The client holds his breath for 10 seconds after inhaling the medication. D. The client exhales as the medication is released from the inhaler.

Correct Answer is C

Explanation

When using an albuterol inhaler, it is important for the client to take a slow and deep inhalation while releasing the medication from the inhaler. After inhaling the medication, holding the breath for about 10 seconds allows the medication to reach deep into the airways and maximize its effectiveness.

The other actions mentioned are not correct:
A. Waiting 10 minutes between inhalations: Albuterol inhalers are typically used as a quick-relief medication for acute symptoms, and waiting 10 minutes between inhalations may not provide immediate relief when needed. The specific instructions on the frequency of inhalations should be provided by the healthcare provider.

B. Taking a quick inhalation while releasing the medication from the inhaler: It is important to take a slow and deep inhalation while releasing the medication to ensure that the medication reaches the lungs effectively. Taking a quick inhalation may result in less effective delivery of the medication.

D. Exhaling as the medication is released from the inhaler: It is important to exhale fully before using the inhaler to ensure that the medication is inhaled deeply into the lungs. Exhaling while releasing the medication can interfere with the proper inhalation technique.

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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?

Nursing Test Bank

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Explanation

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Explanation

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