The practical nurse (PN) is caring for a client with a new prescription for fluticasone furoate nasal spray, a glucocorticoid prescribed for the client's nasal allergy symptoms.
In reinforcing instructions about self-administration of the nasal spray, the PN should emphasize the need for the client to take which action before self-administration?
Exhale through the mouth.
Gently blow the nose.
Check glucose level before and after administration.
Deep breathe and cough.
The Correct Answer is B
This is the action that the PN should emphasize for the client to take before self-administration of the nasal spray because it clears the nasal passages of mucus and debris and allows for better absorption of the medication. The PN should also instruct the client to shake the botle well, tilt the head slightly forward, insert the nozzle into one nostril, close the other nostril with a finger, and press the pump while inhaling gently.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The risk of infection is not the priority nursing problem in this scenario. While the darkened membranes and smoky breath may be indicative of potential infection, addressing ineffective airway clearance is more urgent as it directly impacts the client's breathing and oxygenation.
Choice B rationale:
Ineffective airway clearance should be the priority nursing problem. Darkened membranes of the mouth and smoky breath suggest possible inhalation injury or airway obstruction.
Maintaining a patent airway is crucial for adequate oxygenation and to prevent further complications.
Choice C rationale:
Acute pain is not the priority nursing problem in this case. Although it is essential to address any discomfort the client may be experiencing, it takes a back seat to the more critical issue of ineffective airway clearance.
Choice D rationale:
Disturbed body image is not the priority nursing problem when the client has darkened mouth membranes and smoky breath. While it is important to address body image concerns, the immediate focus should be on managing and improving the client's airway clearance.
Correct Answer is C
Explanation
The correct answer is choiceC. Health care proxy documentation.
Choice A rationale:
The name of the funeral home to contact is not immediately relevant during the admission assessment of a terminally ill client. This information can be collected later as part of end-of-life planning but is not critical for the initial assessment.
Choice B rationale:
While the contact information for the client’s next of kin is important for communication and support, it is not as crucial as health care proxy documentation for making immediate healthcare decisions.
Choice C rationale:
Health care proxy documentation is essential because it designates someone to make healthcare decisions on behalf of the client if they become unable to do so themselves.This ensures that the client’s healthcare preferences and decisions are respected and followed by the healthcare team.
Choice D rationale:
The client’s wishes regarding organ donation are important but are often included in the health care proxy documentation.This information is not as immediately critical as the health care proxy documentation during the admission assessment.
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