A nurse is preparing to administer an otic medication to an adult client. Which of the following actions should the nurse take first?
Ask the client to remain in a side-lying position with the affected ear down for several minutes after instillation.
Pull the client's pinna down and back prior to instillation.
Warm the medication to room temperature before administration.
Press a cotton ball into the client's ear canal after instillation.
The Correct Answer is C
A. Asking the client to remain in a side-lying position comes after administering the drops to facilitate medication retention, but it's not the first action.
B. Pulling the client's pinna down and back straightens the ear canal, but this technique is used for children < 3years. For adults the pinna should be pulled upwards and outwards.
C. Warming the medication may not be necessary to prevent dizziness.
D. Placing a cotton ball in the ear canal after instillation is not necessary for otic medication administration and should not be done routinely.
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Correct Answer is D
Explanation
A. Aspiration is not necessary for subcutaneous insulin injections and is not recommended as it may cause unnecessary trauma.
B. Insulin injections should be administered subcutaneously, typically in the abdomen, but not specifically 2.5 cm from the navel.
C. Insulin injections are not administered into muscle but into the subcutaneous tissue.
D. NPH insulin should be gently rolled between the palms to mix evenly before administration to ensure the suspension is well-mixed.
Correct Answer is A
Explanation
A. Vital signs should be documented in the Objective section of the SOAP note because they are measurable, observable data.
B. The Plan section outlines the actions and treatments planned based on the assessment data.
C. The Action section details the specific interventions carried out during the client's care.
D. The Subjective section includes the client's perceptions, feelings, and statements about their health.
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