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 A
Explanation
Nasal glucocorticoids are commonly used to treat allergic rhinitis and work by reducing inflammation in the nasal passages. However, one of the potential side effects of using these medications is the drying of the nasal mucosa, which can lead to discomfort and occasional nosebleeds. It is important for clients to be aware of this side effect and to take appropriate measures to mitigate it, such as using a humidifier, staying hydrated, and gently applying a saline nasal spray if needed.
Rhinorrhea refers to a runny nose and is not a common side effect of fluticasone or other nasal glucocorticoids. Dizziness and hallucinations are also not typical side effects associated with the use of fluticasone. However, it is important to note that individual responses to medications can vary, and if a client experiences any unusual or concerning side effects while taking fluticasone, they should consult their healthcare provider for further evaluation.
Correct Answer is C
Explanation
Pseudoephedrine is a sympathomimetic medication that acts as a decongestant by constricting blood vessels in the nasal passages, which helps to relieve sinus congestion. However, it can also cause vasoconstriction in other parts of the body, leading to an increase in blood pressure. Therefore, it is contraindicated for individuals with hypertension (high blood pressure).
The other conditions mentioned, migraines, eczema, and diverticulitis, are not contraindications for the use of pseudoephedrine. However, it is important for individuals with these conditions to consult their healthcare provider before taking pseudoephedrine, as it may interact with other medications or exacerbate certain symptoms.
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