A client has an order for a nitroglycerin transdermal patch. The best way to ensure proper administration of this medication is to:
apply it behind the ear.
place it over a hairy skin area.
rotate sites to avoid skin irritation.
put the initials on patch when applied.
The Correct Answer is C
A) Apply it behind the ear: This option is not correct. Nitroglycerin patches are typically applied to hairless areas of the skin to ensure proper adhesion and absorption. The preferred locations are usually the chest, upper arm, or thigh.
B) Place it over a hairy skin area: This action is inappropriate as hair can interfere with the adhesion of the patch and may affect absorption. It is essential to apply the patch to a clean, dry, and hairless area for optimal effectiveness.
C) Rotate sites to avoid skin irritation: This is the correct action. Rotating the application site helps prevent skin irritation and allows for better absorption of the medication. It also reduces the risk of sensitization or reaction at any one site.
D) Put the initials on the patch when applied: While documenting the application is important, simply putting initials on the patch is not sufficient for ensuring proper administration. It is more crucial to ensure that the patch is applied correctly, and monitoring for skin integrity and effectiveness should be part of the nursing care plan.
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Correct Answer is C
Explanation
A) A client who has a question about her daily medications: While it's important to address questions regarding medications, this client does not present an immediate clinical concern that requires urgent attention.
B) A client who needs discharge teaching about an antibiotic: Although discharge teaching is important, it is not an immediate priority compared to the potential instability of a client with chest pain.
C) A client who just received nitroglycerin for chest pain: This is the correct choice. A client who has received nitroglycerin needs to be closely monitored for its effects, including blood pressure and relief of chest pain. This situation is potentially critical, making it the highest priority for assessment.
D) A client who would like some acetaminophen (Tylenol) for a mild headache: While this request should be addressed, it is not as urgent as the need to assess the client who has recently received nitroglycerin. Managing a mild headache is less critical compared to monitoring a client with chest pain.
Correct Answer is D
Explanation
A) While administering the eye drops, a drop lands on the client's outer lid, so the client administers another drop: This action requires further teaching. If a drop lands outside the eye, the client should not administer another drop without first cleaning the area. It’s important to avoid excessive dosing and to ensure the medication is delivered properly.
B) The client cleans the eye from the inner to the outer canthus: This is the correct technique. Cleaning the eye from the inner canthus to the outer canthus helps prevent the spread of debris and ensures a clean area for administering drops.
C) The client looks upward toward the ceiling and administers the eye drops in the conjunctival sac: This action is appropriate. Looking upward helps expose the conjunctival sac, making it easier to administer the drops effectively.
D) The client touches the conjunctival sac with the eyedropper to make sure she is in the correct location: This action requires further teaching. Touching the conjunctival sac with the eyedropper can introduce bacteria and lead to contamination or injury. The client should be advised to keep the dropper tip away from the eye to maintain sterility and safety.