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) Should not be swallowed because it alters the absorption potential: This is the correct explanation. Sublingual medications, such as nitroglycerin, are designed to be absorbed quickly through the mucous membranes under the tongue. Swallowing the medication can significantly reduce its effectiveness and delay absorption, which is crucial for medications used in acute situations like angina.
B) Can be held against the roof of the mouth with the tongue to reduce taste: This option is not correct. Holding the medication against the roof of the mouth does not facilitate the intended sublingual absorption and may not significantly mitigate the taste issue. The medication needs to dissolve under the tongue for effective absorption.
C) Can be inserted rectally without loss of absorption potential: This option is incorrect. Sublingual medications are formulated for absorption through the sublingual mucosa and would not provide the same effects if administered rectally. Different routes of administration have different absorption profiles.
D) Can be taken between the cheek and tongue to diminish taste: While this may help with taste, it does not achieve the desired sublingual absorption. For optimal effect, the medication should be held under the tongue, where it can dissolve and be absorbed directly into the bloodstream.
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.