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:
The role of a case manager involves coordinating and managing a client's care across various healthcare providers and services. This role focuses on the coordination of care and resources, not obtaining informed consent.
Choice B rationale:
The nurse manager is responsible for managing and overseeing nursing staff within a healthcare unit or department. Their primary role is related to administration and staff supervision, not obtaining informed consent.
Choice D rationale:
Researchers are individuals who conduct research studies and investigations to generate new knowledge and evidence. Their role is not related to obtaining informed consent from clients.
Choice C rationale:
The nurse is demonstrating the role of an advocate when obtaining informed consent from a client. Advocacy involves supporting the client's right to make informed decisions about their care. The nurse ensures that the client has all the necessary information, understands the procedure or treatment, and consents voluntarily. This includes explaining the risks and benefits, answering questions, and advocating for the client's autonomy and self-determination.
Correct Answer is B
Explanation
Choice A rationale:
TJC (The Joint Commission) does not provide licensure for healthcare providers. Licensing is typically issued by state regulatory bodies, and it ensures that healthcare professionals meet the minimum qualifications and standards to practice within their respective states. TJC's role is different from providing licensure.
Choice B rationale:
TJC is primarily responsible for accrediting healthcare facilities, including hospitals and clinics, to ensure that they meet specific quality and safety standards. Accreditation by TJC is a mark of quality and demonstrates that the facility complies with nationally recognized healthcare standards.
Choice C rationale:
TJC is not a for-profit organization. It is an independent, non-profit organization dedicated to improving healthcare quality and safety. It does not seek to generate profits but rather focuses on enhancing the quality of care provided to patients.
Choice D rationale:
TJC is not an organization that monitors insurance claims. Monitoring insurance claims is typically the responsibility of insurance companies and regulatory agencies. TJC's primary role is to assess and accredit healthcare facilities to promote patient safety and quality care.
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