The patient is ordered a nasal spray. Which intervention should the nurse instruct the patient to do prior to administration of the nasal spray?

Ask the patient to use the bathroom

Instruct the patient to look up at the ceiling

Ask the patient to take a deep breath

Ask the patient to blow his/her nose to clear the nasal passages

Answer and Explanation

The Correct Answer is D

A. Asking the patient to use the bathroom is unrelated to the administration of nasal spray and is not necessary.
B. Instructing the patient to look up at the ceiling is not required for nasal spray administration and does not facilitate the process.
C. Asking the patient to take a deep breath is not directly related to the administration of nasal spray and does not affect its effectiveness.
D. Asking the patient to blow his/her nose to clear the nasal passages is important before administering nasal spray. Clearing nasal passages helps ensure that the medication can reach the nasal mucosa effectively, improving absorption and efficacy of the spray.

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Correct Answer is C

Explanation

Rationales:
A. Pulling the auricle upward and backward is not recommended for administering eardrops to a child as it does not facilitate proper alignment of the ear canal.
B. Pulling the auricle upward and outward is appropriate when administering eardrops to clients >3years old helps straighten the ear canal, allowing for proper administration of the medication into the ear canal for effective treatment.
C. According to the American Academy of Pediatrics, for children under the age of 3, the correct method is to gently pull the outer flap of the affected ear downward and backward. This maneuver helps to straighten the ear canal, allowing the eardrops to flow down into the canal properly.
D. Pulling the auricle down and outward is not recommended for administering eardrops to a child as it does not facilitate proper alignment of the ear canal.

A. Bring the dropper from below the client's eye to instill the solution. B. Hold the ophthalmic solution 1 to 2 cm (1/2 to 3/4 in) above the lower conjunctival sac. C. Instill the drops into the inner canthus. D. Ask the client to look down when instilling the solution.

Correct Answer is B

Explanation

A. Bringing the dropper from below the client's eye is incorrect as it increases the risk of contamination from the eyelashes.
B. Holding the ophthalmic solution 1 to 2 cm (1/2 to 3/4 in) above the lower conjunctival sac allows for accurate instillation into the eye without touching the dropper tip to the eye or eyelashes.
C. Instilling drops into the inner canthus is incorrect; drops should be placed into the conjunctival sac to ensure proper absorption.
D. Asking the client to look down may help expose the lower conjunctival sac but is not the correct action for administering the drops.

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The patient is ordered a nasal spray. Which intervention should the nurse instruct the patient to do prior to administration of the nasal spray?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer eardrops to a 2-year-old child. The nurse should pull the auricle in which of the following directions when instilling the medication?

Correct Answer is C

Explanation

A nurse is preparing to administer ophthalmic solution to a client. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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