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 A
Explanation
A) Have the client sit up straight: This is the correct action. Sitting up straight helps ensure that the medication can be properly delivered to the nasal passages and increases the likelihood of effective absorption.
B) Leave the other nostril open while giving the medication: While it is often recommended to keep the opposite nostril open to allow for airflow, the medication should be delivered to one nostril at a time. The other nostril should typically be closed or pinched shut to direct the medication effectively.
C) Have the client tilt the head forward: This option is incorrect. Tilting the head forward can make it more difficult for the medication to reach the upper nasal passages. The client should usually keep their head in a neutral position or slightly tilted back.
D) Have the client squeeze the bottle while inhaling: This action is not ideal. The client should inhale gently while the nurse squeezes the atomizer to ensure that the medication is effectively distributed throughout the nasal passages. Squeezing the bottle should be coordinated with inhalation to achieve the best results.
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.