The nurse is preparing to administer ear drops to an adult client. Which of the following actions should the nurse plan to take?
Chill the otic solution prior to administration.
Pull the pinna upward and backward.
Avoid applying pressure to the tragus of the ear.
Don sterile gloves to instill the medication.
The Correct Answer is B
A) Chill the otic solution prior to administration:
Chilling ear drops is not typically necessary or recommended. Cold solutions can cause discomfort or dizziness when instilled into the ear. Room temperature or slightly warmed ear drops are generally more comfortable for the client.
B) Pull the pinna upward and backward:
This is the correct action for administering ear drops to an adult client. Pulling the pinna (outer ear) upward and backward helps straighten the ear canal, allowing the drops to enter the ear canal properly.
C) Avoid applying pressure to the tragus of the ear:
The tragus is the small cartilaginous flap in front of the ear canal. Applying pressure to the tragus can help facilitate the flow of medication into the ear canal rather than avoiding it. Gently pressing on the tragus after instilling the drops can aid in distributing the medication.
D) Don sterile gloves to instill the medication:
Sterile gloves are not typically required for administering ear drops unless the nurse is dealing with a client with a compromised immune system or open ear canal. Standard precautions (clean hands) are usually sufficient for administering ear drops.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) "Your headache is probably a result of anxiety about the chest pain."
Headaches associated with nitroglycerin are typically due to the vasodilatory effects of the medication rather than anxiety. This response does not accurately address the known side effect of nitroglycerin.
B) "A headache is a common adverse effect of this medication, but it will probably occur less often over time."
Headaches are a common side effect of nitroglycerin due to its vasodilatory properties. Over time, some clients may experience less frequent headaches as they adjust to the medication. This response provides accurate information about the medication's side effects and reassures the client that it may improve with continued use.
C) "It sounds as if you are allergic to this medication."
Headaches are a common side effect of nitroglycerin and do not typically indicate an allergic reaction. This response may unnecessarily alarm the client and is not supported by the symptoms presented.
D) "A headache indicates tolerance to the medication."
A headache after nitroglycerin administration is not indicative of tolerance. Tolerance refers to a reduced response to the medication over time, requiring higher doses for the same effect. Headaches are an expected side effect due to vasodilation, not tolerance.
Correct Answer is C
Explanation
A) Limit intake of Vitamin C while taking this medication:
Vitamin C enhances the absorption of iron from ferrous gluconate. Therefore, consuming foods rich in Vitamin C (such as citrus fruits or juices) alongside iron supplements can improve iron absorption. This instruction is incorrect because Vitamin C intake should be encouraged rather than limited.
B) Take this medication with milk:
Taking ferrous gluconate with milk or other dairy products is not recommended because calcium in dairy can inhibit iron absorption. It's preferable to take iron supplements with water or juice to maximize absorption.
C) Take this medication between meals:
Taking ferrous gluconate between meals enhances its absorption because the presence of food can reduce the absorption of iron. Taking it on an empty stomach (about 1 hour before meals or 2 hours after meals) is optimal for absorption.
D) Limit intake of whole grains while taking this medication:
Whole grains contain phytates that can inhibit iron absorption. Therefore, it is beneficial to avoid consuming whole grains at the same time as iron supplements. However, this instruction does not address the timing of medication intake, which is crucial for optimal absorption.
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