The nurse administering a nasal medication via an atomizer bottle should:
have the client sit up straight.
leave the other nostril open while giving the medication.
have the client tilt the head forward.
have the client squeeze the bottle while inhaling.
The Correct Answer is A
A) Have the client sit up straight: This is the correct action. Sitting up straight helps ensure that the medication can be properly delivered to the nasal passages and increases the likelihood of effective absorption.
B) Leave the other nostril open while giving the medication: While it is often recommended to keep the opposite nostril open to allow for airflow, the medication should be delivered to one nostril at a time. The other nostril should typically be closed or pinched shut to direct the medication effectively.
C) Have the client tilt the head forward: This option is incorrect. Tilting the head forward can make it more difficult for the medication to reach the upper nasal passages. The client should usually keep their head in a neutral position or slightly tilted back.
D) Have the client squeeze the bottle while inhaling: This action is not ideal. The client should inhale gently while the nurse squeezes the atomizer to ensure that the medication is effectively distributed throughout the nasal passages. Squeezing the bottle should be coordinated with inhalation to achieve the best results.
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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.
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.