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 B
Explanation
Choice A rationale
Placing the client into a right lateral position is not the standard position for administering an enema. The left lateral (Sims') position is commonly used as it facilitates the flow of the
solution into the colon.
Choice B rationale
Warming the enema solution to room temperature helps ensure the client's comfort and can prevent cramping and discomfort. Cold solutions can cause discomfort and cramping,
making the procedure less tolerable for the client.
Choice C rationale
Sterile technique is not required for administering an enema. Clean technique is generally sufficient unless otherwise indicated by the client’s condition or specific medical orders.
Choice D rationale
Lubricating the tubing is essential to ensure smooth insertion and prevent trauma to the rectal mucosa, but an oil-based lubricant is not typically used as it can interfere with the
absorption of the enema solution. Water-soluble lubricants are preferred.
Correct Answer is C
Explanation
Choice A rationale
The end of the stoma is typically not painful after the procedure. Pain at the stoma site could indicate complications such as infection or ischemia.
Choice B rationale
A healthy stoma should be pink or red in color. A purple color could indicate compromised blood flow or other complications that require medical attention.
Choice C rationale
The stoma is typically placed in the right lower abdomen to allow for easier management and care, as it is usually associated with the terminal ileum.
Choice D rationale
After an ileostomy, the stool is usually liquid to semi-formed, not solid, because the colon, which absorbs water to solidify stool, is bypassed.