A nurse is teaching a client's caregiver how to administer an otic medication to the client. Which of the following statements by the caregiver indicates an understanding of the teaching?
"I will pull the top of the ear up and back before I give the drops."
"I will have them lie flat in bed to give the drops."
"I will wait for the drops to cool before administering them."
"I will tell them to tilt their head back while I am instilling the drops."
The Correct Answer is A
Otic medication administration involves the instillation of sterile or non-sterile solutions into the external auditory canal. Proper positioning of the auricle is essential to straighten the ear canal and ensure the medication reaches the tympanic membrane.
Rationale:
A. Pulling the pinna up and back is the correct technique for an adult client to straighten the external auditory canal. This maneuver allows the drops to flow freely toward the eardrum rather than becoming trapped in the curves of the canal. For children under the age of 3, the nurse should teach the caregiver to pull the pinna down and back instead to achieve the same result.
B. Lying flat in bed is not the ideal position for receiving otic drops, as the medication may not flow deep enough into the canal. The client should be in a side-lying position with the affected ear facing upward to facilitate the gravitational flow of the solution. This position should be maintained for several minutes after instillation to ensure maximum absorption and prevent the medication from leaking out.
C. Cooling otic drops before administration is incorrect because cold solutions can cause extreme discomfort and trigger a vestibular response known as the caloric reflex. This reflex can result in severe vertigo, nausea, and nystagmus. Caregivers should be instructed to warm the medication container by rolling it between their hands to reach body temperature, ensuring a more comfortable and safe administration.
D. Tilting the head back is a technique used for ophthalmic or nasal instillations rather than otic medications. For the ear, the head must be tilted toward the opposite shoulder so the affected ear is horizontal and pointing toward the ceiling. Tilting the head backward would cause the drops to run down the side of the face rather than entering the ear canal effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Sodium polystyrene sulfonate is a cation-exchange resinutilized in the management of hyperkalemia. It works in the large intestine by exchanging sodium ions for potassium ions, allowing the excess potassiumto be excreted from the body via the feces to prevent cardiac complications.
Rationale:
A.While sodium polystyrene sulfonate can lead to a secondary decrease in calcium levels as a side effect, calcium is not the target of the medication. Monitoring calcium is important for safety, but it does not measure the primary effectiveness of the drug. The drug is specifically formulated to treat potassium imbalances that pose immediate risks to the myocardium.
B.Potassium is the primary laboratory value to monitor because the therapeutic goal of sodium polystyrene sulfonate is to lower serum potassium levels. Effectiveness is confirmed when the lab results show a return toward the normal range of 3.5 to 5.0 mEq/L. Since high potassium can cause fatal arrhythmias, this lab provides the definitive proof of the medication's clinical success.
C.Sodium levels may increase during therapy because the resin releases sodium in exchange for potassium, but this is a side effect rather than a measure of efficacy. Monitoring sodium is necessary to prevent hypernatremia and fluid retention, especially in heart failure patients. However, the nurse prioritizes the potassium level to ensure the life-threatening hyperkalemia has been resolved.
D.Magnesium levels are not the primary focus for evaluating the effectiveness of this exchange resin. While electrolyte shifts can occur broadly during diuresis or bowel clear-out, sodium polystyrene sulfonate has a specific affinity for potassium. The nurse should monitor magnesium for general electrolyte balance, but it does not serve as a benchmark for the medication's intended therapeutic action.
Correct Answer is ["0.75"]
Explanation
Step 1 is to identify the ordered dose and the available dosage strength
Ordered Dose: 60 mg
Available Strength: 80 mg / 1 mL
Step 2 is to calculate the number of milliliters to administer
Volume to administer = (Ordered Dose ÷ Available Dose) × Available Volume
Volume to administer = (60 ÷ 80) × 1
60 ÷ 80 = 0.75
0.75 × 1 = 0.75
Volume to administer = 0.75 mL
Step 3 is to round to the nearest hundredth
0.75 = 0.75
Answer: 0.75 mL
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