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) Upward and back: This direction is appropriate for adults and older children but not for infants. The anatomy of an infant's ear canal requires a different approach for effective eardrop administration.
B) Upward and outward: This option is also incorrect for infants. Similar to option A, this technique does not effectively account for the anatomical differences in an infant's ear canal.
C) Downward and back: This is the correct action when administering eardrops to an infant. Pulling the auricle downward and back straightens the ear canal, allowing for better access to deeper structures and ensuring that the drops reach the intended area.
D) Downward and inward: This direction is not appropriate for straightening the ear canal. The correct technique is to pull downward and back to achieve the desired angle for effective administration of eardrops in infants.
Correct Answer is A
Explanation
A) Discard the pill and get another from the dose pack: This option is the most appropriate action. Once a pill has fallen onto the bed linens, it may be contaminated and should not be administered to the client. The nurse should discard the dropped pill and provide a new one to ensure patient safety and maintain hygiene standards.
B) Scoop up the pill in a soufflé cup and hand the cup to the client: This action is inappropriate as it fails to address potential contamination. A pill that has fallen onto bedding may carry bacteria or other pathogens, so it should not be given to the client even if it is retrieved in a different container.
C) Retrieve the pill from the linens and allow the client to take it: This option is unsafe and violates infection control protocols. Giving a pill that has been dropped on bedding poses a risk of contamination and should be avoided.
D) Report the loss of the pill as a medication error: While reporting medication errors is important, in this case, the action taken (discarding the pill and providing a new one) aligns with best practices. The loss of one pill due to a drop does not constitute a medication error in the same sense as an administration mistake, so this option is not necessary.