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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

The vastus lateralis muscle is the preferred intramuscular injection site for infants and children due to its large muscle mass and lack of major nerves or blood vessels, minimizing the risk of injury. This site is easily accessible and provides a safe area for medication absorption in developing musculature.

Choice B rationale

The ventrogluteal site is generally considered safe and effective for intramuscular injections, but it requires precise anatomical landmark identification, which can be challenging in infants and young children, increasing the risk of sciatic nerve injury if landmarks are not accurately identified.

Choice C rationale

The dorsogluteal site is contraindicated for intramuscular injections in infants and children due to the risk of sciatic nerve damage. The sciatic nerve runs through this area, and the muscle mass is not fully developed in younger patients, making it a hazardous site.

Choice D rationale

The deltoid muscle is too small and underdeveloped in infants and young children to safely accommodate intramuscular injections. Its limited muscle mass increases the risk of injury to underlying nerves and blood vessels, and absorption capacity is reduced.

A. Explain that the doctor probably changed her drug today to something more effective for her illness, and administer it. B. Tell her briefly the action of the red tablet and administer it. C. Withhold the drug until you have rechecked the MAR with her doctor's order sheet. D. Administer the medication, but make a mental note to check on it later.

Correct Answer is C

Explanation

Choice A rationale

Administering medication without verifying the order, especially when the patient expresses concern about a change in appearance, is a breach of medication safety principles. The patient's concern highlights a potential discrepancy, and simply explaining a possible change without confirmation is unprofessional and dangerous.

Choice B rationale

This action is incorrect and dangerous. The patient stated she always takes a yellow pill, but the nurse is preparing to administer a blue tablet. Telling her the action of a "red tablet" is confusing, indicates a potential misunderstanding of the medication, and demonstrates a failure to address the patient's valid concern about the color discrepancy.

Choice C rationale

When a patient questions a medication, especially regarding its appearance, it is imperative to withhold the drug and recheck the medication administration record (MAR) against the physician's original order. This verifies that the correct medication, dose, and form are being administered, preventing potential medication errors and ensuring patient safety.

Choice D rationale

Administering the medication and making a mental note to check later is unsafe practice. A patient's concern about medication is a critical alert. Ignoring it and administering the drug first could lead to serious adverse effects if a medication error has occurred. Verification must precede administration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nursing instructor asks the student nurse which of the following intramuscular (IM) sites is preferred in infants and children. What should the student nurse's response be?

Correct Answer is A

Explanation

After handing your client her medication, she says, "What is this blue tablet for? I have always taken a yellow pill.”. Your most appropriate action would be to:

Correct Answer is C

Explanation

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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?