A nurse is administering nasal decongestant drops for a client.
Which of the following actions should the nurse take?
Assist the client to a side-lying position.
Hold the dropper 2 cm (1 in) above the naris.
Instruct the client to stay in the same position for 2 min.
Tell the client to blow her nose gently before the instillation.
The Correct Answer is D
The correct answer is choice D.
Choice A rationale:
Assisting the client to a side-lying position is not necessary when administering nasal decongestant drops. The client can be in an upright position or slightly tilted back.
Choice B rationale:
Holding the dropper 2 cm (1 in) above the naris is not a standard guideline for administering nasal decongestant drops. The dropper should be inserted into the nostril without touching the inside of the nostril to avoid contamination.
Choice C rationale:
Instructing the client to stay in the same position for 2 min is not necessary. After the administration of the nasal decongestant drops, the client can resume their normal activities.
Choice D rationale:
Telling the client to blow her nose gently before the instillation is the correct action. This action will help remove any secretions or crusts that could interfere with the distribution and absorption of the medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
There are actually five rights of delegation: right task, right circumstance, right person, right direction/communication, and right supervision/evaluation. This statement is not accurate.
Choice B rationale:
It is not the duty of the delegatee to perform a task without asking questions. Effective delegation involves clear communication, including the opportunity for the delegatee to ask questions and seek clarification as needed.
Choice C rationale:
While the nurse manager plays a role in delegation, the responsibility for delegation does not solely rest on the nurse manager. Delegation is a shared responsibility among all nurses, and the person delegating the task must ensure it is appropriate and clear.
Correct Answer is D
Explanation
Choice A rationale:
While the principle of justice is essential in healthcare, it does not directly address the client's decision to proceed with elective surgery or not. Justice pertains more to the fair allocation of resources and the equitable treatment of individuals, which may not directly apply to the client's autonomy in this situation.
Choice B rationale:
The principle of fidelity relates to keeping promises and being faithful to commitments, but it may not be the primary ethical principle to consider in this situation. The client's decision to proceed with elective surgery is primarily a matter of personal autonomy, and the nurse should prioritize respecting the client's autonomy over fidelity.
Choice C rationale:
Veracity is the principle of truthfulness and honesty in communication, but it does not take precedence over the client's autonomy in this context. While it is important for the nurse to provide honest information, the client's autonomous decision to proceed with or decline surgery should be respected regardless of the nurse's communication of truthful information. .
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