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 ["1200"]
Explanation
Step 1::00 pm in military time is 1200. The PM hours in the 12-hour clock align with the 12th hour in military time for 12: pm. Answer: 1200.
Correct Answer is A
Explanation
Choice A rationale
Tolerance is a physiological adaptation to a drug, characterized by a decreased response to the same dose, or a need for increased doses to achieve the same effect. In this case, the increased dosage of morphine over several weeks indicates that the client's body has adapted to the drug's effects, requiring more to manage pain.
Choice B rationale
An adverse reaction is an undesirable and unintended effect of a drug, occurring at normal doses. While an increased dosage might lead to adverse effects, the described scenario specifically highlights the need for a higher dose to maintain efficacy, which is characteristic of tolerance, not simply an adverse reaction.
Choice C rationale
Idiosyncrasy refers to an unpredictable, uncharacteristic, or exaggerated response to a drug that is not an allergic reaction. It is typically a genetically determined abnormal response that occurs with initial exposure or after a few doses, unlike tolerance which develops over time with repeated exposure.
Choice D rationale
Polypharmacy refers to the concurrent use of multiple medications by a patient, often more than medically necessary. While the client is receiving medication, the scenario specifically describes a change in dosage of a single medication due to a diminished response, which is characteristic of tolerance, not polypharmacy.
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