The nurse is preparing to administer ear drops to an adult client. Which of the following actions should the nurse plan to take?
Chill the otic solution prior to administration.
Pull the pinna upward and backward.
Avoid applying pressure to the tragus of the ear.
Don sterile gloves to instill the medication.
The Correct Answer is B
A) Chill the otic solution prior to administration:
Chilling ear drops is not typically necessary or recommended. Cold solutions can cause discomfort or dizziness when instilled into the ear. Room temperature or slightly warmed ear drops are generally more comfortable for the client.
B) Pull the pinna upward and backward:
This is the correct action for administering ear drops to an adult client. Pulling the pinna (outer ear) upward and backward helps straighten the ear canal, allowing the drops to enter the ear canal properly.
C) Avoid applying pressure to the tragus of the ear:
The tragus is the small cartilaginous flap in front of the ear canal. Applying pressure to the tragus can help facilitate the flow of medication into the ear canal rather than avoiding it. Gently pressing on the tragus after instilling the drops can aid in distributing the medication.
D) Don sterile gloves to instill the medication:
Sterile gloves are not typically required for administering ear drops unless the nurse is dealing with a client with a compromised immune system or open ear canal. Standard precautions (clean hands) are usually sufficient for administering ear drops.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) A client taking a potassium supplement twice a day:
Taking potassium supplements can actually lower the risk of digoxin toxicity because hypokalemia (low potassium levels) increases the risk of digoxin toxicity. Potassium supplements help maintain adequate potassium levels, which is beneficial for clients taking digoxin.
B) A client taking aluminum hydroxide for gastric upset:
Aluminum hydroxide can bind to digoxin in the gastrointestinal tract, reducing its absorption. This interaction can decrease the effectiveness of digoxin rather than increase the risk of toxicity.
C) A client taking chlorpropamide for type 2 diabetes mellitus:
Chlorpropamide does not interact significantly with digoxin or affect electrolyte levels in a way that would increase the risk of digoxin toxicity.
D) A client taking furosemide for chronic hypertension:
Furosemide, a loop diuretic, can cause hypokalemia and hypomagnesemia, which are risk factors for digoxin toxicity. Low potassium levels enhance the toxicity of digoxin by increasing its binding to cardiac tissue receptors, leading to enhanced cardiac effects.
Correct Answer is A
Explanation
A) The client should use an electric razor while on this medication:
Using an electric razor is recommended for clients taking warfarin because it reduces the risk of cuts and bleeding, which can be difficult to control due to the anticoagulant effects of warfarin. This advice helps minimize the risk of injury and excessive bleeding.
B) Warfarin increases the risk for deep vein thrombosis:
Warfarin is an anticoagulant that is actually used to prevent and treat deep vein thrombosis (DVT) and other thromboembolic conditions. This statement is incorrect because warfarin reduces the risk of clot formation, rather than increasing it.
C) Nose bleeds are common during initial treatment:
While nosebleeds can occur as a side effect of warfarin due to its anticoagulant properties, they are not considered common or normal. Persistent or frequent nosebleeds should be reported to a healthcare provider, as they may indicate that the dosage needs adjustment.
D) If he misses a dose, he should double the dose at the next scheduled time:
Doubling the dose of warfarin if a dose is missed is not recommended. Doing so can significantly increase the risk of bleeding. The correct action for a missed dose is to take it as soon as remembered, but if it is close to the time for the next dose, skip the missed dose and continue with the regular schedule. Clients should follow specific instructions from their healthcare provider regarding missed doses.
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