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) "Clients who have rheumatoid arthritis should not take warfarin":
Rheumatoid arthritis itself is not a contraindication for warfarin therapy. However, close monitoring is required due to potential interactions with medications used to treat rheumatoid arthritis and the increased risk of bleeding associated with both conditions.
B) "Clients who have diabetes mellitus type 1 should not take warfarin":
Type 1 diabetes mellitus is not a contraindication for warfarin therapy. However, diabetes increases the risk of complications such as peripheral vascular disease, which may necessitate careful monitoring of INR levels and adjustments to warfarin dosage.
C) "Clients who have hypertension should not take warfarin":
Hypertension alone is not a contraindication for warfarin therapy. However, hypertension is a risk factor for cardiovascular diseases that may require anticoagulation therapy. Close monitoring of blood pressure and potential interactions with antihypertensive medications is essential.
D) "Clients who are pregnant should not take warfarin":
Pregnancy is a contraindication for warfarin therapy due to its teratogenic effects, which can cause fetal harm or birth defects. Pregnant clients requiring anticoagulation therapy may be prescribed alternative medications that are safer during pregnancy, under the guidance of a healthcare provider.
Correct Answer is D
Explanation
A) "Take the medication on an empty stomach":
Taking baclofen with food can help reduce gastrointestinal side effects such as nausea. However, the instruction to take it on an empty stomach is not necessary or typically recommended. Ensuring consistent timing with or without food is more practical for adherence and reducing potential side effects.
B) "Stop taking the medication immediately for headache":
While headaches can be a side effect of baclofen, stopping the medication abruptly can lead to withdrawal symptoms or worsening of muscle spasticity. It's important to discuss any persistent or severe headaches with the healthcare provider to determine the appropriate management.
C) "Diarrhea is an adverse effect of this medication":
Diarrhea can indeed be a side effect of baclofen, but it is not one of the primary or most common side effects. Constipation is actually more frequently observed. Monitoring for gastrointestinal changes and discussing them with the healthcare provider is important for appropriate management.
D) "Avoid driving until the medication's effects are evident":
This instruction is crucial because baclofen can cause drowsiness or dizziness, especially when starting the medication or when the dosage is adjusted. It is important for the client to avoid activities such as driving until they are aware of how the medication affects them to ensure safety.
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