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:
Ensuring that the television is on is not a recommended action when providing discharge teaching for an adolescent with a cognitive disorder and their parents. Television noise can be distracting and may hinder effective communication. The focus should be on clear, concise, and tailored communication to address the patient's and family's needs.
Choice B rationale:
Using short directive statements is a suitable approach when teaching a patient with a cognitive disorder and their parents. Patients with cognitive disorders may have difficulty processing complex information, so using concise and straightforward language can enhance understanding. It is essential to adapt teaching strategies to the individual's needs and abilities.
Choice C rationale:
Including medical slang in the teaching is not appropriate, as it can confuse and alienate patients and their families. The goal of discharge teaching is to ensure that the information provided is clear, easily understood, and accessible to the patient and their family. Using medical jargon or slang may hinder this objective.
Choice D rationale:
Including abstract imagery is not recommended when teaching a patient with a cognitive disorder. Abstract imagery can be challenging to understand, especially for individuals with cognitive impairments. Teaching materials should be concrete, straightforward, and tailored to the patient's cognitive abilities and comprehension levels.
Correct Answer is C
Explanation
Choice A rationale:
Phlebitis is inflammation of a vein, often associated with pain, redness, and warmth at the catheter site. In this case, the client's catheter site is described as cool and taut, which is not consistent with the manifestations of phlebitis.
Choice B rationale:
Infection typically presents with signs such as redness, warmth, swelling, and pain at the catheter site. The description of the client's catheter site as cool and taut is not indicative of infection.
Choice C rationale:
The client's symptoms, including a cool and taut catheter site and IV fluid leaking, are indicative of infiltration. Infiltration occurs when IV fluids inadvertently enter the surrounding tissue instead of the vein. It can lead to localized swelling and discomfort.
Choice D rationale:
Circulatory overload is characterized by symptoms such as shortness of breath, elevated blood pressure, and tachycardia. These symptoms are not consistent with the client's description of a cool and taut catheter site with IV fluid leaking.
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