A nurse is to administer one nose drop to each nostril of a school-aged child.
Which action should the nurse perform as part of this procedure?
Position the child in the supine position with the head tilted backward when inserting the drops.
Instruct the child to breathe deeply through the nose after the drop is inserted.
Return the unused nose drops in the dropper to the medication bottle.
Position the tip of the medication dropper within a nostril when expelling the drop.
The Correct Answer is A
Choice A rationale
Positioning a school-aged child in the supine position with the head tilted backward during nose drop administration allows gravity to assist the medication in flowing into the nasal cavity and reaching the intended mucosal surfaces. This anatomical alignment ensures optimal distribution and absorption of the drug, maximizing its therapeutic effect on the nasal passages.
Choice B rationale
Instructing the child to breathe deeply through the nose immediately after drop insertion could cause the medication to be inhaled into the lungs or swallowed, reducing its intended topical effect on the nasal mucosa. Proper technique involves maintaining the head position for a few moments to allow absorption.
Choice C rationale
Returning unused nose drops from the dropper to the medication bottle is an unsafe practice that can lead to contamination of the entire medication supply. The dropper tip, once it has touched the patient's nostril, is no longer sterile and can introduce microbes into the sterile solution.
Choice D rationale
Positioning the tip of the medication dropper within a nostril can cause discomfort, irritation, or even injury to the delicate nasal mucosa. The dropper should be held just above the nostril, allowing the drops to fall into the nasal passage without direct contact, ensuring patient safety and comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The abdomen, specifically 2 inches from the umbilicus, is a common site for subcutaneous injections due to the presence of ample adipose tissue, which allows for slower absorption of medications like insulin or heparin. Intradermal injections require a site with a thin epidermis and minimal subcutaneous tissue to ensure the medication remains within the dermal layer, making the abdomen unsuitable.
Choice B rationale
The anterior thigh is a common site for intramuscular injections, particularly in infants, due to the large muscle mass (vastus lateralis). While it can be used for subcutaneous injections, its muscularity and varying skin thickness make it less ideal for the precise shallow angle required for an intradermal injection, where the goal is to deposit the medication into the dermis.
Choice C rationale
The posterior upper arm, specifically the triceps area, is frequently utilized for subcutaneous injections, such as insulin or certain vaccines, because it offers sufficient subcutaneous tissue. However, similar to the anterior thigh, its anatomical characteristics with thicker skin and subcutaneous fat layers make it less optimal for the very superficial intradermal injection technique.
Choice D rationale
The upper chest, particularly below the clavicle and above the breasts, is an appropriate site for intradermal injections. This area, along with the inner forearm and upper back, has a thin epidermis and less subcutaneous tissue, which facilitates the proper placement of the medication within the dermis, allowing for the formation of a visible wheal, a key indicator of a successful intradermal injection.
Correct Answer is ["0.45"]
Explanation
Step 1 is to determine the volume to administer. 4500 units ÷ (10,000 units/1 mL) = 0.45 mL. The nurse will administer 0.45 mL.
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