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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

The correct answer is Choice D: Obtaining a blood pressure for a client who is to be discharged later in the day.

Choice A rationale:

Providing tracheostomy care requires specialized training and assessment skills, which are beyond the scope of practice for assistive personnel (AP).

Choice B rationale:

Assessing a client who just returned from surgery involves clinical judgment and decision-making, which are responsibilities of a licensed nurse, not assistive personnel.

Choice C rationale:

Teaching a client how to use an incentive spirometer requires patient education skills and the ability to assess the client's understanding, which are tasks for a licensed nurse.

Choice D rationale:

Obtaining a blood pressure is a routine task that can be delegated to assistive personnel, as it does not require advanced clinical judgment or specialized training.

A. Guide the client away from background noise. B. Provide a copy of the instructions printed in Braille. C. Stand next to the client when speaking. D. Repeat any phrases that the client misunderstands.

Correct Answer is C

Explanation

Choice A rationale:

Guiding the client away from background noise is a helpful suggestion for a client with hearing loss, but in the context of reviewing discharge instructions, it may not be sufficient. The primary issue is not background noise but the ability of the client to hear and understand the nurse's instructions.

Choice B rationale:

Providing a copy of the instructions printed in Braille is not appropriate for a client with hearing loss. Braille is a tactile reading and writing system for people who are blind or visually impaired. It does not address the client's hearing loss.

Choice C rationale:

Standing next to the client when speaking is the most appropriate action for a nurse when reviewing discharge instructions with a client who has hearing loss. This allows the client to see the nurse's facial expressions, lip movements, and gestures, which can aid in understanding. It also minimizes the distance between the nurse's mouth and the client's ears, making it easier for the client to hear.

Choice D rationale:

While repeating phrases that the client misunderstands is a helpful communication strategy, it should be used in conjunction with standing close to the client, not as the sole method. Standing close and speaking clearly should be the primary approach to facilitate effective communication with a client who has hearing loss.

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A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take?

Nursing Test Bank

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A nurse is administering nasal decongestant drops for a client.
Which of the following actions should the nurse take?