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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View Related questions
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.
Correct Answer is D
Explanation
A) Cerumen or drainage is occluding the ear canal: While cerumen or drainage can cause discomfort, it is less likely to be the direct cause of dizziness following the administration of eardrops. Dizziness is more commonly associated with changes in pressure or temperature in the ear.
B) Too much pressure was applied during instillation, with subsequent injury to the eardrum: Although excessive pressure can lead to injury, the immediate symptom of dizziness after eardrop administration is more closely related to other factors, particularly temperature or positioning.
C) The client failed to remain in the side-lying position long enough: This option is incorrect because not maintaining the position may affect medication absorption but is unlikely to cause immediate dizziness and nausea.
D) The medication was too cold when it was administered: This is the most likely cause of the dizziness. Cold eardrops can cause a rapid change in temperature within the ear canal, potentially stimulating the vestibular system and leading to dizziness or vertigo. It is generally recommended to warm eardrops to body temperature before administration to minimize this risk.