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 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 C
Explanation
A) A client who has a question about her daily medications: While it's important to address questions regarding medications, this client does not present an immediate clinical concern that requires urgent attention.
B) A client who needs discharge teaching about an antibiotic: Although discharge teaching is important, it is not an immediate priority compared to the potential instability of a client with chest pain.
C) A client who just received nitroglycerin for chest pain: This is the correct choice. A client who has received nitroglycerin needs to be closely monitored for its effects, including blood pressure and relief of chest pain. This situation is potentially critical, making it the highest priority for assessment.
D) A client who would like some acetaminophen (Tylenol) for a mild headache: While this request should be addressed, it is not as urgent as the need to assess the client who has recently received nitroglycerin. Managing a mild headache is less critical compared to monitoring a client with chest pain.