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) Measure liquid medication by bringing liquid medication cup to eye level: This is the correct action. Measuring liquid medications at eye level ensures accuracy and helps the nurse confirm the correct dosage, minimizing the risk of administration errors.
B) Crush enteric-coated medication and place it in a medication cup with water: This option is incorrect. Enteric-coated medications are designed to dissolve in the intestine, not in the stomach, and crushing them can alter their effectiveness and increase the risk of side effects. These medications should be administered whole.
C) Place all of the client's medications in the same cup, except medications with assessments: This option is not advisable without knowing how the medications interact. Certain medications may have specific requirements for administration and should not be mixed together, as this could lead to confusion or adverse reactions.
D) Remove the medication from the wrapper and place it in a cup labeled with the client's information: While labeling is crucial for safety, medications should ideally be kept in their original packaging until administration to prevent confusion and ensure that the nurse has all necessary information about the medication at hand. Medications should only be removed when preparing for immediate administration.
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.