A nurse is administering nasal decongestant drops for a client.
Which of the following actions should the nurse take?
Assist the client to a side-lying position.
Hold the dropper 2 cm (1 in) above the naris.
Instruct the client to stay in the same position for 2 min.
Tell the client to blow her nose gently before the instillation.
The Correct Answer is D
The correct answer is choice D.
Choice A rationale:
Assisting the client to a side-lying position is not necessary when administering nasal decongestant drops. The client can be in an upright position or slightly tilted back.
Choice B rationale:
Holding the dropper 2 cm (1 in) above the naris is not a standard guideline for administering nasal decongestant drops. The dropper should be inserted into the nostril without touching the inside of the nostril to avoid contamination.
Choice C rationale:
Instructing the client to stay in the same position for 2 min is not necessary. After the administration of the nasal decongestant drops, the client can resume their normal activities.
Choice D rationale:
Telling the client to blow her nose gently before the instillation is the correct action. This action will help remove any secretions or crusts that could interfere with the distribution and absorption of the medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Tell the APs they are acting immature. Telling the APs that they are acting immature is a judgmental and unhelpful approach. It does not demonstrate conflict resolution but rather exacerbates the conflict. This choice is not appropriate for resolving the situation.
Choice B rationale:
Allow the APs to resolve their issues. While allowing individuals to resolve their issues on their own can sometimes work, it is not always the best approach, especially in a healthcare setting where teamwork and patient care are paramount. In this scenario, the nurse should play an active role in resolving the conflict, making this choice less suitable.
Choice C rationale:
Confront the APs to discuss their argument. Confronting the APs to discuss their argument is a proactive approach to conflict resolution. It allows the nurse to address the issue, mediate the disagreement, and work towards a resolution. This choice is the most appropriate and demonstrates effective conflict resolution.
Choice D rationale:
Report the APs to the charge nurse. Reporting the APs to the charge nurse should be considered when the conflict cannot be resolved at the staff level, and it threatens patient care or safety. However, it should not be the first step in resolving a conflict between two individuals. It is a more formal and escalated approach, and in this case, choice C is a more suitable initial response.
Correct Answer is ["A","B","C","D"]
Explanation
Findings that Could Increase Susceptibility to Infection:
-
Budesonide 6 mg PO daily:
- Explanation: Budesonide is a corticosteroid used to reduce inflammation, often prescribed for conditions like Crohn's disease. While it helps manage inflammation, corticosteroids also suppress the immune system. This immunosuppressive effect can increase the client's susceptibility to infections.
-
BMI of 16:
- Explanation: A BMI of 16 is considered underweight. Malnutrition or being underweight can weaken the immune system, making a person more susceptible to infections because their body lacks the necessary nutrients and energy to support immune function.
-
History of Type 2 Diabetes Mellitus:
- Explanation: Diabetes, particularly if not well-controlled, can impair the immune system and increase the risk of infections. High blood sugar levels can hinder the function of immune cells, making it easier for infections to develop and harder for the body to fight them.
-
New Diagnosis of Crohn's Disease:
- Explanation: Crohn's disease is an inflammatory bowel disease that causes inflammation of the digestive tract. This chronic inflammation can affect the body's ability to absorb nutrients, leading to nutritional deficiencies that impair the immune system. Additionally, the disease itself, especially when active, can increase the risk of infection.
Findings That Do Not Increase Susceptibility to Infection:
-
Hematocrit (Hct) of 47%:
- Explanation: The Hct level is within the normal range of 37% to 52%. It measures the percentage of red blood cells in the blood. Since it's normal, it does not indicate an increased risk of infection.
-
Hemoglobin (Hgb) of 16 g/dL:
- Explanation: The Hgb level is also within the normal range of 12 to 18 g/dL. Hemoglobin is a protein in red blood cells that carries oxygen. This normal level does not suggest a higher risk of infection.
-
Potassium level of 3.6 mEq/L:
- Explanation: Potassium levels are within the normal range of 3.5 to 5.0 mEq/L. This electrolyte level is unrelated to infection risk in the context provided.
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