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 C
Explanation
Choice A rationale:
Tell the APs they are acting immature. Telling the APs that they are acting immature is a judgmental and unhelpful approach. It does not demonstrate conflict resolution but rather exacerbates the conflict. This choice is not appropriate for resolving the situation.
Choice B rationale:
Allow the APs to resolve their issues. While allowing individuals to resolve their issues on their own can sometimes work, it is not always the best approach, especially in a healthcare setting where teamwork and patient care are paramount. In this scenario, the nurse should play an active role in resolving the conflict, making this choice less suitable.
Choice C rationale:
Confront the APs to discuss their argument. Confronting the APs to discuss their argument is a proactive approach to conflict resolution. It allows the nurse to address the issue, mediate the disagreement, and work towards a resolution. This choice is the most appropriate and demonstrates effective conflict resolution.
Choice D rationale:
Report the APs to the charge nurse. Reporting the APs to the charge nurse should be considered when the conflict cannot be resolved at the staff level, and it threatens patient care or safety. However, it should not be the first step in resolving a conflict between two individuals. It is a more formal and escalated approach, and in this case, choice C is a more suitable initial response.
Correct Answer is B
Explanation
Choice A rationale:
The novice-to-expert model for nursing competence includes several stages, and the "novice" stage represents a beginner who has limited experience and lacks clinical support. This stage typically involves individuals who are just starting their nursing careers and are in the early phases of learning.
Choice B rationale:
An "advanced beginner" is the next stage in the novice-to-expert model. This stage is characterized by individuals who have gained some experience and can perform tasks with increased competence. However, they still require clinical support and guidance in certain situations. It's a transitional phase between complete novice and more proficient levels of competence.
Choice C rationale:
The "proficient" stage in the model represents nurses who have acquired a higher level of competence and are capable of handling a wide range of situations. They do not require the same level of clinical support as those in the advanced beginner stage.
Choice D rationale:
The "competent" stage represents nurses who have reached a high level of competence and can function effectively in most situations without continuous clinical support. They are highly skilled and experienced in their practice.
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