A nurse has been administering mucolytic-like Hypertonic Nasal drops to an infant she has been caring for. How can she chart the effectiveness of this medication in her narrative note?
The infant tolerated the instillation of the nose drops without any shortness of breath or fever.
Saline nose drops inserted Infant cried a small amount
The infant tolerated the insertion of saline nose drops well
Saline nose drops were inserted into both nares.
Large random breath respirations 26/minute.
Correct Answer : A,C,D
"The infant's nasal congestion appeared to improve following the administration of hypertonic nasal drops. The infant tolerated the insertion of saline nose drops well, with no signs of distress or adverse reactions. The nasal passages appeared clearer after the instillation, and the infant's breathing appeared less congested. There was no significant increase in respiratory rate or other signs of respiratory distress observed. The intervention seemed to have a positive effect on the infant's nasal congestion."
This statement indicates that the mucolytic medication (hypertonic nasal drops) was administered and had a positive effect on the infant's nasal congestion. It also mentions that the infant tolerated the procedure well without any adverse reactions, such as shortness of breath or fever. The absence of distress or adverse symptoms and the observed improvement in nasal congestion indicate the effectiveness of the medication in the nurse's narrative note. The additional information about the saline nose drops and respiratory rate may not directly address the effectiveness of the mucolytic medication and can be documented separately if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Expectorants are medications that help thin and loosen mucus in the respiratory tract, making it easier to cough up and clear from the airways. Increasing fluid intake, particularly water helps to keep the mucus thin and less sticky, facilitating its removal. Adequate hydration can help promote effective expectoration and relieve congestion.
The other options are incorrect because:
B. Taking the medication once a day only, usually at bedtime: The dosing frequency and timing of expectorants can vary depending on the specific medication prescribed. It is important to follow the healthcare provider's instructions regarding the dosing schedule.
C. Increase fiber and fluid intake to prevent constipation: This instruction is unrelated to expectorant use. Increasing fiber and fluid intake is commonly recommended to promote regular bowel movements and prevent constipation, but it is not directly related to expectorant therapy.
D. Restrict fluids to decrease mucus production: Restricting fluids can lead to dehydration and thickening of mucus secretions. It is important to stay adequately hydrated to maintain thin and easily expectorated mucus. Restricting fluids is not recommended for managing mucus production.
Correct Answer is A
Explanation
A. Albuterol is a bronchodilator that provides quick relief by relaxing the muscles around the airways, making it essential to use before a corticosteroid like beclomethasone, which reduces inflammation. Using albuterol first allows for better delivery of the beclomethasone to the airways.
B. I will use both medications immediately after exercising. Albuterol may be used as a rescue inhaler before exercise to prevent exercise-induced bronchospasm, but beclomethasone is a maintenance medication and should not be used immediately after exercising unless prescribed.
C. "If my breathing begins to feel tight, I will use the beclomethasone inhaler immediately.” Beclomethasone is a long-term control medication, not a rescue inhaler. If breathing feels tight or there is an asthma attack, the client should use the albuterol inhaler for immediate relief.
D. I will administer the medications 10 minutes apart.While there is no strict rule about the timing between inhaler uses, the albuterol should be used first to open the airways, and while waiting a few minutes is acceptable, the emphasis should be on using albuterol before beclomethasone rather than a specific time frame.
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