A client receiving ophthalmic drugs reports blurred vision....

A client receiving ophthalmic drugs reports blurred vision. He tells the nurse, 'I almost fell yesterday.' The nurse identifies which nursing diagnosis?

A. Risk for Infection
B. Risk for Injury
C. Acute Pain
D. Anxiety

Correct Answer: B

Rationale: The client's complaint of blurred vision and his report of almost falling support the nursing diagnosis of Risk for Injury. Risk for Infection would be appropriate if the client had an infection or did not correctly instill the eyedrops, contaminating the container and/or solution. Acute Pain would be more appropriate if the client complained of pain either from the disorder or as an adverse effect. Although the client may be anxious, there is no evidence to support it.

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When assessing an infant for a possible ear infection, which of the following behaviors would the nurse note? Select all that apply.

A. Change in behavior
B. Nasal drainage
C. Irritability
D. Ear tugging
E. Fever

Correct Answer: A,C,D,E

Rationale: When assessing the infant, the nurse would look for ear tugging, change in behavior, crying, fussing or irritability, or fever.

Before administering an otic preparation, which of the following would the nurse be responsible for during the preadministration assessment? Select all that apply.

A. Documentation of a description of any drainage
B. Examination of the outer structures of the earlobe
C. Examination of the inner structures of the ear
D. Documentation of a description of visible cerumen
E. Examination of the skin around the ear

Correct Answer: A,B,D,E

Rationale: During preadministration assessment before administering an otic preparation, the nurse is responsible for the following: examination of the outer structures of the ear (earlobe and the skin around the ear) and documentation of a description of any drainage or visible cerumen. The primary health care provider examines the ear's external and internal structures.

A client is receiving multiple ophthalmic drugs. Which of the following ophthalmic preparations would the nurse administer to the client for the purpose of treating increased intraocular pressure? Select all that apply.

A. Brimonidine (Alphagan)
B. Apraclonidine (Iopidine)
C. Tobramycin (TobraDex)
D. Ofloxacin (Ocuflox)
E. Ganciclovir (Vitrasert)

Correct Answer: A,B

Rationale: Brimonidine (Alphagan) and apraclonidine (Iopidinare ophthalmic preparations used to treat increased intraocular pressure.

The ophthalmic preparation erythromycin (Ilotycin) is contraindicated in clients with which of the following? Select all that apply.

A. Gonorrheal infection of the eye
B. Varicella infection of the eye
C. Fungal infection of the eye
D. Epithelial herpes simplex keratitis of the eye
E. Mycobacterial infection of the eye

Correct Answer: B,C,D,E

Rationale: Antibiotic ophthalmic preparations, like erythromycin (Ilotycin), are contraindicated in clients with the following: epithelial herpes simplex keratitis, varicella, mycobacterial, and fungal infections of the eye.

A client would like to use carbamide peroxide (Debrox) to remove cerumen from the ears and asks the nurse if this is okay. In which of the following situations should this drug not be used? Select all that apply.

A. Before ear surgery
B. Perforated eardrum
C. Congestion
D. Ear drainage
E. Dizziness

Correct Answer: B,D

Rationale: Drugs like Debrox (carbamide peroxide), used to remove cerumen, are not used if ear discharge, drainage, pain, or irritation is present, if the eardrum is perforated; or after ear surgery.