A nurse is reinforcing teaching about self-administration of nasal drops with a client. Which of the following positions should the nurse recommend for instillation of the drops?
Sims
Prone
Supine
Orthopneic
The Correct Answer is C
When instructing a client on self-administration of nasal drops, the nurse should recommend the supine position. In the supine position, the client lies on their back with the head slightly elevated. This position allows for easy access to the nostrils and facilitates the proper instillation of the nasal drops.
The other options are not recommended for instillation of nasal drops for various reasons:
a) Sims position: Sims position is a side-lying position with the upper leg flexed. This position is often used for rectal examinations or procedures and is not suitable for instilling nasal drops.
b) Prone position: Prone position refers to lying face down. It is not ideal for administering nasal drops as it
can obstruct proper access to the nostrils and make it difficult to instill the drops accurately.
d) Orthopneic position: Orthopneic position is a sitting position with the upper body supported by pillows. It is commonly used by individuals with respiratory distress to facilitate breathing. However, it is not specifically recommended for administering nasal drops as it may not provide optimal access to the nostrils for proper instillation.
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Related Questions
Correct Answer is B
Explanation
b. FLACC Scale.
Explanation: The FLACC (Face, Legs, Activity, Cry, Consolability) Scale is a pain assessment tool commonly used for infants and young children who are unable to self-report their pain. It assesses five categories of behavior: facial expression, leg movement, activity level, cry, and consolability. Each category is scored from 0 to 2 or 0 to 3, depending on the specific scale used. The scores are then totaled to provide an overall pain assessment.
The FACES Scale, also known as the Wong-Baker FACES Pain Rating Scale, is a tool commonly used for children who can understand and self-report their pain. It consists of a series of faces with different expressions representing varying degrees of pain.
The Color tool is not a recognized pain rating tool. It may refer to an assessment of skin color, which can be used to assess oxygenation or circulation but not specifically for pain.
The Numeric scale is a pain rating tool that involves asking the individual to rate their pain on a scale from 0 to 10, with 0 being no pain and 10 being the worst pain imaginable. However, this scale may not be suitable for a 3-month-old infant who is unable to comprehend numbers or communicate effectively.
Correct Answer is D
Explanation
Performing oral care every 2 hours is an important nursing intervention for a client receiving mechanical ventilation via an endotracheal tube. This helps to reduce the risk of ventilator-associated pneumonia.
a) Monitoring the client's vital signs is important, but it should be done more frequently than every 8 hours.
b) Repositioning the endotracheal tube is not necessary unless there is a specific indication.
c) Placing the client in a supine position is not recommended as it increases the risk of aspiration.
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