The UAP reports the client is complaining of dizziness and nausea after the administration of eardrops. What is the most likely cause of the dizziness?
Cerumen or drainage is occluding the ear canal.
Too much pressure was applied during instillation, with subsequent injury to the eardrum.
The client failed to remain in the side-lying position long enough.
The medication was too cold when it was administered.
The Correct Answer is D
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.
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Correct Answer is C
Explanation
A) 6 weeks from the start of using the inhaler: This option is not accurate. The timing for refilling should be based on the actual usage rather than a fixed period, and 6 weeks may not align with the client’s actual consumption.
B) As soon as the client leaves the hospital: This option is premature. The client does not need to refill the inhaler immediately upon discharge since they may not have used many puffs yet.
C) 50 days after discharge: This is the correct answer. If the client is to administer 2 puffs twice daily, that totals 4 puffs per day. With 200 puffs in the inhaler, the inhaler would last for 50 days (200 puffs ÷ 4 puffs per day = 50 days). Advising the client to refill the medication approximately 50 days after discharge ensures they have enough medication available.
D) When the inhaler is half empty: This option could lead to refilling too early or too late, depending on the individual’s usage pattern. Advising to refill based on a specific number of days or puffs used provides a more precise recommendation.
Correct Answer is ["C","D","E"]
Explanation
A) Fill only the center of the conjunctival sac: This option is incorrect. When applying ophthalmic ointment, the ointment should be placed along the entire length of the conjunctival sac, not just the center, to ensure proper distribution and effectiveness.
B) Remove excess ointment from the lid with a cotton ball: This action is not recommended. Instead of using a cotton ball, which may introduce fibers or contaminants, excess ointment should be gently wiped away with a clean tissue or cloth if necessary. However, it is generally best to avoid excess application in the first place.
C) Remove gloves and perform hand hygiene: This option is correct. After applying the ointment, the nurse should remove gloves and perform hand hygiene to prevent any potential contamination and maintain proper infection control practices.
D) Ask the client to roll the eye around and from side to side: This is a correct action. Encouraging the client to roll their eyes helps distribute the ointment evenly across the surface of the eye, enhancing its effectiveness.
E) Ask the client to close the eyelids tightly to distribute ointment: This option is also correct. Closing the eyelids helps spread the ointment over the conjunctival surface, ensuring better coverage and absorption of the medication.