A nurse is administering oral medications to patients. Which action will the nurse take?
Measure liquid medication by bringing liquid medication cup to eye level.
Crush enteric-coated medication and place it in a medication cup with water.
Place all of the client's medications in the same cup, except medications with assessments.
Remove the medication from the wrapper and place it in a cup labeled with the client's information.
The Correct Answer is A
A) Measure liquid medication by bringing liquid medication cup to eye level: This is the correct action. Measuring liquid medications at eye level ensures accuracy and helps the nurse confirm the correct dosage, minimizing the risk of administration errors.
B) Crush enteric-coated medication and place it in a medication cup with water: This option is incorrect. Enteric-coated medications are designed to dissolve in the intestine, not in the stomach, and crushing them can alter their effectiveness and increase the risk of side effects. These medications should be administered whole.
C) Place all of the client's medications in the same cup, except medications with assessments: This option is not advisable without knowing how the medications interact. Certain medications may have specific requirements for administration and should not be mixed together, as this could lead to confusion or adverse reactions.
D) Remove the medication from the wrapper and place it in a cup labeled with the client's information: While labeling is crucial for safety, medications should ideally be kept in their original packaging until administration to prevent confusion and ensure that the nurse has all necessary information about the medication at hand. Medications should only be removed when preparing for immediate administration.
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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 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.