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A nurse at an ophthalmology clinic is providing teaching to a client who has open-angle glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the following instructions should the nurse provide?
- A. Administer the medications 5 minutes apart.
- B. Hold pressure on the conjunctival sac for 2 minutes following application of drops.
- C. It is not necessary to remove contact lenses before administering medications.
- D. Administer the medications by touching the tip of the dropper to the sclera of the eye.
Correct Answer: A
Rationale: The correct answer is A: Administer the medications 5 minutes apart. Timolol and pilocarpine are both used to treat glaucoma but work differently. Timolol is a beta-blocker that reduces intraocular pressure while pilocarpine constricts the pupil to improve drainage. Administering them 5 minutes apart prevents one medication from washing out the other. Choice B is incorrect as pressure on the conjunctival sac is not necessary. Choice C is incorrect as contact lenses should be removed before administering eye drops. Choice D is incorrect as touching the dropper tip to the eye can lead to infections.
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A nurse working on a medical unit is completing the admission of a client who reports a severe allergy to penicillin. Which of the following actions should the nurse take?
- A. Remove all objects that contain latex from the client’s room.
- B. Verify the client’s medication prescriptions do not include cephalosporin.
- C. Notify dietary services to adjust the client’s diet.
- D. Have the client purchase a medication alert bracelet to wear in the hospital.
Correct Answer: B
Rationale: The correct answer is B: Verify the client’s medication prescriptions do not include cephalosporin. This is essential because cephalosporins are antibiotics that share a similar structure to penicillin and can potentially cause an allergic reaction in individuals with a penicillin allergy. By ensuring that the client's medication prescriptions do not include cephalosporin, the nurse is taking a proactive step to prevent any adverse reactions.
Removing objects containing latex (choice A) is not directly related to the client’s penicillin allergy. Notifying dietary services to adjust the client’s diet (choice C) is unnecessary as the allergy is to penicillin, not food. Having the client purchase a medication alert bracelet (choice D) is not as immediate or essential as verifying medication prescriptions.
A nurse is assessing a client who is receiving vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?
- A. Decrease the infusion rate on the IV.
- B. Document that the client experienced an anaphylactic reaction to the medication.
- C. Change the IV infusion site.
- D. Apply cold compresses to the neck area.
Correct Answer: A
Rationale: The correct answer is A: Decrease the infusion rate on the IV. Flushing of the neck and tachycardia are common signs of "Red Man Syndrome," a potential adverse reaction to vancomycin infusion. Decreasing the infusion rate can help alleviate these symptoms. Documentation (B) of an anaphylactic reaction is inaccurate because these symptoms are not indicative of an anaphylactic reaction. Changing the IV site (C) is unnecessary as the symptoms are likely due to the medication itself. Applying cold compresses (D) is not effective for this reaction.
A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?
- A. A client who has a small circular partial-thickness burn of the left calf.
- B. A client who has severe respiratory stridor and a deviated trachea.
- C. A client who has a splinted open fracture of the left medial malleolus.
- D. A client who has a massive head injury and is experiencing seizures.
Correct Answer: B
Rationale: The correct answer is B. The client with severe respiratory stridor and a deviated trachea should be assessed first as this indicates a compromised airway, which is a life-threatening emergency. Immediate intervention is crucial to prevent respiratory arrest. Clients with airway issues should always be the top priority in triage.
Other choices are incorrect because:
A: Small circular partial-thickness burn of the left calf is not immediately life-threatening and can be addressed after addressing more critical conditions.
C: Splinted open fracture of the left medial malleolus, while serious, does not present an immediate threat to the client's life compared to compromised airway.
D: Massive head injury and seizures are also serious, but in this scenario, the client with compromised airway takes precedence as airway issues can lead to rapid deterioration.
A nurse is assessing a client who is admitted for elective surgery and has a history of Addison’s disease. Which of the following findings should the nurse expect?
- A. Purple striations
- B. Hirsutism
- C. Hyperpigmentation
- D. Intention tremors
Correct Answer: C
Rationale: The correct answer is C: Hyperpigmentation. Addison's disease is characterized by adrenal insufficiency, leading to decreased production of cortisol and aldosterone. This results in increased production of ACTH, which can cause hyperpigmentation, especially in sun-exposed areas. Purple striations (A) are seen in Cushing's syndrome, not Addison's. Hirsutism (B) is excessive hair growth, commonly seen in conditions like polycystic ovary syndrome, not Addison's. Intention tremors (D) are associated with cerebellar dysfunction, not typically seen in Addison's.
A nurse is caring for a client who has acute respiratory distress syndrome (ARDS) and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?
- A. Induce sedation.
- B. Suppress respiratory effort.
- C. Decrease chest wall compliance.
- D. Decrease respiratory secretions.
Correct Answer: B
Rationale: The correct answer is B: Suppress respiratory effort. Pancuronium is a neuromuscular blocking agent that paralyzes skeletal muscles, including the muscles involved in breathing. In ARDS, the client may have difficulty breathing due to lung damage, so pancuronium can be used to facilitate mechanical ventilation by preventing respiratory muscle movement. This allows the ventilator to control the client's breathing without interference. The other choices are incorrect because pancuronium does not induce sedation (A), affect chest wall compliance (C), or decrease respiratory secretions (D). It solely works to suppress respiratory effort by blocking neuromuscular transmission.