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:
A heart rate of 56 beats per minute is within the normal range for an adult, so a high temperature of 39°C (102.2°F) is not directly related to the heart rate. While elevated body temperature can increase heart rate, the given temperature does not indicate a significant fever.
Choice B rationale:
History of cigarette smoking may be a risk factor for cardiovascular issues, but it does not directly correlate with the current heart rate of 56 beats per minute. The low heart rate is more likely related to other factors.
Choice C rationale:
A heart rate of 56 beats per minute is considered bradycardia, which can lead to dizziness, fatigue, and other symptoms. Dizziness is a common finding in individuals with a slow heart rate, and addressing this symptom is essential for patient safety.
Choice D rationale:
Hypoglycemia (low blood sugar) can cause symptoms like dizziness, but the heart rate is not typically affected directly by hypoglycemia. It is important to address both the bradycardia and the reported dizziness to determine the underlying cause and provide appropriate care.
Correct Answer is C
Explanation
Choice A rationale:
The National Student Nurses Association is primarily focused on students and recent graduates. While it can be an excellent organization for student nurses, it may not provide opportunities for a nurse looking to become involved in nursing on a national level beyond their student years.
Choice B rationale:
The National Academy of Medicine is an organization that focuses on health policy and research. While it is a prestigious organization, it is not specifically a nursing organization, and its focus may not align with the goals of a nurse seeking to become more involved in nursing on a national level.
Choice C rationale:
The American Nurses Association (ANA) is a national organization specifically dedicated to advancing the nursing profession. It offers various opportunities for nurses to get involved in national-level nursing advocacy, policy development, and professional growth. Joining the ANA is a suitable choice for a nurse looking to make a national impact in the field of nursing.
Choice D rationale:
The National League for Nursing (NLN) is an organization that primarily focuses on nursing education. While it plays a crucial role in the field of nursing, its focus is more on education and may not align with a nurse's goal to become involved in nursing on a national level from a broader perspective.
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