A nurse is preparing to administer a metered dose inhaler (MDI) medication to a client.
Which of the following actions should the nurse take?
Ask the client to hold their breath for 2 seconds after inhalation.
Wash the MDI canister in warm water after each use.
Ask the client to inhale the medication quickly for 1 second.
Shake the MDI prior to administration.
The Correct Answer is D
Choice A rationale
Clients should be instructed to hold their breath for about 10 seconds after inhalation, not 2 seconds. This allows the medication to reach deeper into the lungs.
Choice B rationale
The MDI canister should not be washed after each use. Instead, it should be cleaned regularly to ensure proper functioning and avoid medication buildup.
Choice C rationale
Clients should be instructed to inhale the medication slowly and deeply over a few seconds, rather than quickly for 1 second. This ensures proper delivery of the medication to the lungs.
Choice D rationale
Shaking the MDI prior to administration is essential. This action mixes the medication evenly, ensuring that the correct dose is delivered with each puff.
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Correct Answer is D
Explanation
Choice A rationale
A sigmoid colostomy usually produces stool that is more formed compared to an ileostomy. This is because the colostomy is created from the sigmoid colon, where water absorption occurs.
Choice B rationale
The stoma should not be painful after the procedure. Pain may indicate complications, and the stoma itself lacks nerve endings.
Choice C rationale
The stoma should be a bright red or pink color, indicating good blood supply. A purple color could suggest ischemia or poor blood flow.
Choice D rationale
A sigmoid colostomy is typically located in the left lower abdomen because the sigmoid colon is situated in this area of the body.
Correct Answer is C
Explanation
Choice A rationale
Returning the opened medication to the medication cart is inappropriate because once a medication is opened and refused by a client, it must be disposed of properly. This action helps maintain safety and prevents contamination.
Choice B rationale
Reporting the incident to the provider is not necessary in this context as the refusal to take medication can be managed by the nurse by following the facility's protocol.
Choice C rationale
Filling out an incident report is required because the client's refusal to take the medication is considered a significant event. Incident reports are used to document and analyze such events to improve patient care and safety.
Choice D rationale
Notifying the facility's ethics committee is unnecessary for a medication refusal incident, as it does not involve an ethical dilemma requiring their intervention.