The ear canal should be straightened when instilling eardrops to provide direct access to deeper ear structures. In what direction should the auricle be pulled in an infant to straighten the ear canal?
Upward and back.
Upward and outward.
Downward and back.
Downward and inward.
The Correct Answer is C
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.
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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 B
Explanation
A) Ask the client if he would prefer to give the medication to himself: While involving the client in their care is important, this option does not assess the client’s ability to safely take the medication. The nurse should first ensure that the client can swallow the medication safely.
B) Assess the swallowing reflex by offering a sip of water: This is the correct action. Assessing the swallowing reflex is essential, especially in older adults, to determine if they can safely swallow liquid medications without risk of aspiration.
C) Mix thoroughly in applesauce or pudding: This option is not appropriate unless specifically ordered or indicated. Mixing medications in food may not be suitable for all clients, and it can affect the medication's absorption or effectiveness. Additionally, it does not assess the client's swallowing ability.
D) Assess the ability to understand information relative to the medication: While this is important, it is secondary to ensuring that the client can physically take the medication safely. Assessing understanding can occur after confirming the client’s ability to swallow the medication.