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
The correct answer is Choice A.
Choice A rationale: Using a cell phone to request assistance from the client's room ensures timely communication and enhances patient care. Quick access to help can be vital in emergency situations, ensuring prompt and effective intervention.
Choice B rationale: Sending a personal text to a co-worker during work hours is unprofessional and can lead to distractions. It can compromise patient care and violates workplace policies on personal device usage, ensuring focus remains on patient safety and care.
Choice C rationale: Calling the client's family member per their request can violate privacy and confidentiality regulations, such as HIPAA in the US. Communication with family should go through proper channels to ensure compliance with legal and ethical standards.
Choice D rationale: Taking a photo of a client's incision site for learning purposes without proper consent and documentation breaches patient confidentiality and privacy. It could also result in legal ramifications and violates institutional policies on using personal devices for work-related tasks.
Correct Answer is D
Explanation
Choice D rationale:
Protecting a client's safety by not causing harm refers to the ethical principle of nonmaleficence. Nonmaleficence emphasizes the duty of healthcare professionals to avoid harm or minimize harm when providing care to clients. This principle is closely related to the concept of "do no harm" and places a high value on the well-being and safety of the client. Nurses must make decisions and take actions that prioritize the client's safety and well-being, even when faced with difficult ethical dilemmas.
Choice A rationale:
Beneficence is the ethical principle that emphasizes doing good and promoting the well-being of the client. While it is an essential ethical principle in nursing, it is not directly related to the concept of not causing harm, as described in the question.
Choice B rationale:
Fidelity, also known as faithfulness or loyalty, pertains to the nurse's obligation to uphold commitments and keep promises made to the client. While fidelity is crucial in nursing practice, it is not the primary principle related to the concept of not causing harm.
Choice C rationale:
Justice is the ethical principle concerned with fairness and the equitable distribution of healthcare resources and treatment. It focuses on providing clients with their due and ensuring that they are treated fairly and without discrimination. Justice is important in healthcare ethics but is not directly associated with the principle of not causing harm.
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