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 A
Explanation
Choice A rationale:
Health promotion is the correct concept demonstrated by the nurse. Health promotion refers to activities and strategies that aim to enhance an individual's overall health and well-being. Educating the client with heart disease about the importance of eating a heart-healthy diet is a proactive step towards improving their health.
Choice B rationale:
Holistic health is a broader approach that considers the whole person, including physical, mental, and social aspects. While it is an important concept, the nurse, in this scenario, is primarily focused on educating the client about a specific aspect of their health, which is heart disease management.
Choice C rationale:
Health education is a component of health promotion, but it specifically refers to the process of providing individuals with knowledge and skills to make informed decisions about their health. In this case, the nurse is providing education as a means of promoting the client's health.
Choice D rationale:
Primary prevention involves measures to prevent the development of a disease or condition before it occurs. While promoting a heart-healthy diet is a form of prevention, it does not specifically align with the concept of primary prevention, which typically involves actions taken to avoid the initial occurrence of a health problem.
Correct Answer is D
Explanation
Atrial fibrillation with a rapid heart rate can lead to decreased cardiac output and compromised blood flow, which can have serious consequences, including stroke and heart failure. Therefore, this client requires immediate attention to assess and manage the cardiac rhythm.
While the other clients also have significant health concerns, they are not as acutely life-threatening as a new onset of atrial fibrillation with a high heart rate. Prioritizing care based on the urgency and severity of the condition is crucial in the emergency department setting.
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