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A nurse is administering multiple types of ophthalmic drugs to a client. Which of the following actions should the nurse take?
- A. Hold the dropper 3 cm (1.2 in) away from the client's eye.
- B. Ask the client to close their eyes tightly after instilling each medication.
- C. Massage the client's eyelids for 2-3 seconds after instillation.
- D. Wait 5 min between the administration of each medication.
Correct Answer: D
Rationale: The correct answer is D: Wait 5 min between the administration of each medication. This is important to prevent dilution or interaction between the different ophthalmic medications. Administering multiple medications too close together can reduce the effectiveness of each medication. Holding the dropper at a specific distance (A) is not as critical as allowing time between administrations. Asking the client to close their eyes tightly (B) or massaging the eyelids (C) after instillation can disrupt the medication and should be avoided. Waiting for 5 minutes allows each medication to be properly absorbed before the next one is administered, ensuring optimal therapeutic effects.
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A nurse is caring for a client who has a traumatic brain injury and needs to relearn how to use eating utensils. The nurse should refer the client to which of the following members of the interprofessional team?
- A. Physical therapist
- B. Speech-language pathologist
- C. Occupational therapist
- D. Social worker
Correct Answer: C
Rationale: The correct answer is C: Occupational therapist. Occupational therapists specialize in helping individuals regain skills needed for daily activities, such as using eating utensils. They focus on enhancing fine motor skills and cognitive abilities necessary for independent living. Referring the client to an occupational therapist will ensure a comprehensive approach to relearning utensil use. Physical therapists (A) focus on mobility and strength, not fine motor skills. Speech-language pathologists (B) address communication and swallowing issues, not utensil use. Social workers (D) assist with psychosocial support, not utensil retraining.
A nurse is teaching a class about the guidelines for the standards of care for nursing. Which of the following defines the nursing scope of practice?
- A. The JEN Consultant
- B. Podcast League for Nursing
- C. Postnote ID # of Rights
- D. State Nurse Practice Acts
Correct Answer: D
Rationale: The correct answer is D: State Nurse Practice Acts. State Nurse Practice Acts define the legal scope of practice for nurses in each state, outlining what tasks and responsibilities nurses can perform. These acts help ensure patient safety and quality care by setting standards for nursing practice. Choice A, B, and C are unrelated to nursing scope of practice and do not provide any guidelines or regulations for nurses. Therefore, they are incorrect options.
A home health nurse is providing teaching about home safety to an older adult client. Which of the following examples of home safety should the nurse include in the teaching?
- A. Obtain a raised toilet seat for the bathroom.
- B. Secure loose wires under carpeting.
- C. Use extension cords to prevent overloading circuits.
- D. Cover slippery stairs with an area rug.
Correct Answer: A
Rationale: The correct answer is A: Obtain a raised toilet seat for the bathroom. This is important for older adults to prevent falls and make it easier for them to use the toilet safely. Raised toilet seats reduce the risk of strain or injury while sitting down or getting up.
Incorrect choices:
B: Securing loose wires under carpeting can still pose a tripping hazard.
C: Using extension cords can lead to electrical hazards and fires.
D: Covering slippery stairs with an area rug can increase the risk of falls due to slipping.
A nurse is preparing to administer prescribed medications to a client. According to the rights of medication administration, when should the nurse compare the medication administration record against the medication container? (Select all that apply.)
- A. While removing medication from the container
- B. Before selecting the medication container
- C. When documenting the medication administration
- D. When providing client education about the medication
- E. At the client's bedside before administering the medication
Correct Answer: A, B,E
Rationale: The correct answers are A, B, and E. Comparing the medication administration record against the container before removing the medication ensures accuracy. Before selecting the container, the nurse confirms the correct medication. At the client's bedside, the nurse verifies the medication before administration to prevent errors. Choice C is incorrect because documentation should occur after administration. Choice D is incorrect as medication reconciliation is not part of client education.
A nurse is assessing a client's cranial nerve VII. Which of the following responses should the nurse expect?
- A. The client turns their head against resistance.
- B. The client's tongue is in a midline position.
- C. The client's pupils constrict in response to light.
- D. The client has a symmetrical smile.
Correct Answer: D
Rationale: The correct answer is D: The client has a symmetrical smile. Cranial nerve VII, the facial nerve, controls facial expression including smiling. When assessing this nerve, the nurse would expect the client to have a symmetrical smile indicating intact function. This is because cranial nerve VII innervates the muscles of facial expression. Choices A, B, and C are incorrect as they are not specific to cranial nerve VII assessment. The turning of the head against resistance (A) would be more related to cranial nerve XI, the accessory nerve. The tongue position (B) is controlled by cranial nerve XII, the hypoglossal nerve. Pupillary constriction in response to light (C) is regulated by cranial nerve II, the optic nerve.