Nokea
A nurse is preparing to administer Auralgan Otic drops, which contain benzocaine, antipyrine, and glycerin. The nurse understands that these drops provide which type of action? Select all that apply.
- A. Antifungal
- B. Corticosteroid
- C. Emollient
- D. Analgesic
- E. Local anesthetic
Correct Answer: C,D,E
Rationale: Auralgan Otic contains a local anesthetic (benzocaine), an emollient (glycerin), and an analgesic (antipyrine).
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Trifluridine is being administered to a patient who is being treated for epithelial keratitis. The nurse caring for this patient should know that which of the following is a local reaction to trifluridine?
- A. Edema of the eyes
- B. Loss of visual acuity
- C. Cataract formation
- D. Delayed wound healing
Correct Answer: A
Rationale: Trifluridine is an antiviral drug, and administration of antiviral ophthalmics may cause local reactions such as edema of the eyes or eyelids, irritation, pain, pruritus, inflammation, foreign body sensation, and corneal clouding. Loss of visual acuity, cataract formation, and delayed wound healing are the local adverse reactions associated with the administration of corticosteroid ophthalmic preparations like dexamethasone phosphate and are not related to the administration of trifluridine.
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.
A nurse is caring for a patient who is prescribed 1% hydrocortisone/4.71 mg neomycin (Coly-Mycin S Otifor bacterial infections of the external auditory canal. Which of the following instructions should be followed by the nurse administering the otic solution?
- A. When the patient is upright, remove the solution running out of the ear with gauze.
- B. After instilling the drops, insert a cotton piece deep into the ear to keep the drops in.
- C. Keep the patient lying on the untreated side for 30 minutes after instilling the drops.
- D. Insert the applicator or dropper tip sufficiently to reach into the external auditory canal.
Correct Answer: A
Rationale: Once the patient is upright, the solution running out of the ear may be gently removed with gauze. A piece of cotton can be loosely inserted into the ear canal, but it should never be inserted deeply because if inserted too deeply it may cause increased pressure within the ear canal. The patient is kept lying on the untreated side after the medication is instilled for approximately 5 minutes to facilitate the penetration of the drops into the ear canal. The nurse should not insert the applicator of dropper tip anywhere into the ear or allow the tip to become contaminated.
After teaching a client how to administer eye drops, the nurse determines that additional teaching is needed when the client states which of the following?
- A. I'll check to make sure the solution is clear.
- B. I'll drop the solution into the nasal side of the lower eye sac.
- C. I'll be sure not to touch the tip of the dropper to the eye.
- D. I'll check the label to make sure it reads for 'ophthalmic use'
Correct Answer: B
Rationale: When administering eye drops, the client should check the label to make sure the preparation is for ophthalmic use and it is clear. The client should drop the solution into the middle of the lower conjunctival sac, not directly on the eyeball. The tip should not come into contact with the eye to prevent contamination.
The nurse should discuss which of the following adverse reactions with a client prior to the administration of dexamethasone (Maxidex)? Select all that apply.
- A. Increased intraocular pressure
- B. Headache
- C. Numbness
- D. Ptosis
- E. Cataract formation
Correct Answer: A,D,E
Rationale: The nurse should discuss the following adverse reactions with a client prior to the administration of an ophthalmic corticosteroid, like dexamethasone (Maxidex): increased intraocular pressure with optic nerve damage, loss of visual acuity, cataract formation, delayed wound healing, secondary ocular infection, exacerbation or corneal infections, dry eyes, ptosis, blurred vision, discharge, ocular pain, foreign body sensation, and pruritus.