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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A) Activated partial thromboplastin time (aPTT): This test is primarily used to monitor the effectiveness of heparin therapy, not warfarin. While aPTT measures the intrinsic pathway of coagulation, it is not the standard test for monitoring warfarin, which affects the extrinsic pathway and vitamin K-dependent clotting factors.

B) Platelet count: This test measures the number of platelets in the blood and is used to diagnose and monitor conditions related to platelet function, such as thrombocytopenia. However, it does not provide information about the anticoagulant effect of warfarin, which works by inhibiting vitamin K-dependent clotting factors.

C) White blood cell count (WBC): This test measures the number of white blood cells in the blood and is used to diagnose and monitor infections and inflammatory conditions. It is not relevant for monitoring the anticoagulant effect of warfarin, as WBC levels are not influenced by warfarin therapy.

D) Prothrombin time (PT): This is the correct test to monitor the effect of warfarin therapy. PT measures the extrinsic pathway of coagulation, which is directly influenced by warfarin. The international normalized ratio (INR) is derived from the PT and is used to standardize PT results, making it the most reliable indicator of warfarin’s anticoagulant effect. Regular monitoring of PT/INR helps ensure therapeutic levels are maintained while minimizing the risk of bleeding complications.

A. Draw up the NPH insulin into the syringe first. B. Inject air into the regular insulin first. C. Shake the NPH insulin until it is well-mixed D. Discard regular insulin if it appears cloudy

Correct Answer is D

Explanation

A) Dyspnea:
Diphenhydramine primarily addresses allergic reactions such as urticaria (hives) rather than respiratory symptoms like dyspnea associated with blood transfusion reactions.

B) Fever:
The administration of diphenhydramine during blood transfusions is aimed at mitigating allergic reactions, particularly urticaria, rather than fever as a symptom.

C) Low-back pain:
Diphenhydramine is not indicated for preventing or managing low-back pain, which is not typically associated with allergic reactions to blood transfusions.

D) Urticaria:
Diphenhydramine is administered to prevent or reduce symptoms of allergic reactions, particularly urticaria (hives), which can occur during blood transfusions due to immune responses to transfused blood components.

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The nurse is preparing to administer ear drops to an adult client. Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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