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 B
Explanation
Choice A rationale:
Including a note in the medical record that an incident report was completed is a crucial step in documenting the event. It serves as a legal and organizational record of the incident, providing transparency and accountability. This information can be essential for tracking trends, identifying areas for improvement, and ensuring patient safety.
Choice B rationale:
Identifying other people involved with the event in the incident report is also an important step. It helps in determining who was present or responsible during the incident, which can be crucial in investigating the event and identifying potential areas for process improvement.
Choice C rationale:
Including personal opinions regarding an event in an incident report is not advisable. Incident reports should focus on factual, objective information. Personal opinions can introduce bias and subjectivity, which may not be helpful in addressing the root causes of the incident or improving the quality of care.
Choice D rationale:
Identifying the person responsible for the error in the incident report is a valid step, as it helps in assigning accountability and addressing any systemic issues that may have contributed to the error. However, it's essential to do so without assigning blame or making judgments. The emphasis should be on improving processes and preventing similar incidents in the future.
Correct Answer is C
Explanation
Choice A rationale:
Material safety data sheets (MSDS) primarily contain information related to hazardous chemicals and substances used in healthcare settings. While MSDS can be valuable for safety purposes, they do not provide comprehensive information on specimen collection protocols. Therefore, MSDS is not the most appropriate source for revising the specimen collection protocol.
Choice B rationale:
Client medical records are essential for individual patient care and documentation. However, they do not contain the information needed to revise the protocol for specimen collection on the unit. Medical records are specific to individual patient histories, diagnoses, and treatments, and do not address broader unit-wide protocols.
Choice C rationale:
Facility policy and procedures are the most appropriate source for retrieving information to revise the protocol for specimen collection on the unit. These policies and procedures are specifically designed to guide healthcare providers in delivering safe and effective care within the facility. They encompass standardized protocols for various clinical procedures, including specimen collection, making them the ideal source for the nurse's research.
Choice D rationale:
Evidence-based practice (EBP) involves using the best available research evidence, clinical expertise, and patient values to guide healthcare decisions. While EBP is crucial in healthcare, it is not the primary source for revising unit-specific protocols. EBP provides a broader framework for making clinical decisions but may not cover the specific policies and procedures unique to the facility.
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