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 C
Explanation
A) "Heparin enhances the effects of the warfarin.": This statement is incorrect. Heparin and warfarin work through different mechanisms. Heparin acts quickly by inhibiting clot formation through antithrombin, while warfarin acts slower by inhibiting vitamin K-dependent clotting factors. They do not directly enhance each other's effects.
B) "Both heparin and warfarin work together to dissolve the clots.": This is inaccurate. Neither heparin nor warfarin dissolve existing clots; they prevent new clots from forming and existing clots from growing. The body's natural processes will eventually dissolve the clot.
C) "Heparin will be continued until the warfarin reaches a therapeutic level!": This is correct. Heparin is used initially because it acts quickly. Warfarin takes several days to reach therapeutic levels. Overlapping the two ensures continuous anticoagulation until warfarin is effective.
D) "I will ask the charge nurse to call your provider and get an explanation.": While involving the provider for further explanation can be helpful, it does not directly answer the client’s question. Providing accurate information about the overlapping use of heparin and warfarin is more appropriate in this context.
Correct Answer is B
Explanation
A) Have suction equipment at the bedside:
Having suction equipment at the bedside is not specifically related to the administration of clopidogrel. It may be necessary for clients with respiratory or airway concerns but is not directly associated with this medication.
B) Monitor the client for black, tarry stools:
Clopidogrel is an antiplatelet medication that can increase the risk of bleeding, including gastrointestinal bleeding. Monitoring for black, tarry stools is essential as it can indicate upper gastrointestinal bleeding, which is a potential adverse effect of clopidogrel therapy.
C) Initiate contact precautions:
Contact precautions are not required for clients taking clopidogrel. Clopidogrel does not pose an infection risk that would necessitate contact precautions.
D) Administer the medication with each meal:
Clopidogrel is typically administered once daily, regardless of meals. There is no specific requirement to administer it with each meal.
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