A nurse is administering nasal decongestant drops for a client.
Which of the following actions should the nurse take?
A.
Assist the client to a side-lying position.
B.
Hold the dropper 2 cm (1 in) above the naris.
C.
Instruct the client to stay in the same position for 2 min.
D.
Tell the client to blow her nose gently before the instillation.
The correct answer is:
D. Tell the client to blow her nose gently before the instillation.
Explanation:
Before administering nasal decongestant drops, it is important for the client to blow their nose gently to clear the nasal passages. This helps ensure that the medication can reach the nasal mucosa effectively and work as intended.
Here’s why the other options are less appropriate:
- A. Assist the client to a side-lying position: The client should generally be in a sitting position with their head tilted back slightly, rather than lying on their side. This position allows the drops to be evenly distributed in the nasal passages.
- B. Hold the dropper 2 cm (1 in) above the naris: The dropper should be held close to the nares (but not touching them) to accurately administer the drops into the nasal passages. Holding it 2 cm above is appropriate, but ensuring it does not touch the nares is important for cleanliness and accuracy.
- C. Instruct the client to stay in the same position for 2 min: While it’s helpful to have the client remain in the same position briefly after administration to allow the medication to be absorbed, 2 minutes may be excessive. Typically, just a minute or less is sufficient.
Correct answer: D