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After returning home, a client who has had cataract surgery will need to continue to instill eye drops in the affected eye. The client is instructed to apply slight pressure against the nose at the inner canthus of the eye after instilling the eyedrops. The rationale that supports applying pressure is that it:
- A. Prevents the medication from entering the tear duct.
- B. Prevents the drug from running down the client's face.
- C. Allows the sensitive cornea to adjust to the medication.
- D. Facilitates distribution of the medication over the eye surface.
Correct Answer: A
Rationale: Applying pressure at the inner canthus (punctal occlusion) prevents the medication from draining into the tear duct, which could lead to systemic absorption or reduced effectiveness of the eye drops.
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The client with a fractured tibia has been taking methocarbamol (Robaxin). Which of the following indicate that the drug is having the intended effect?
- A. Lack of infection.
- B. Reduction in itching.
- C. Relief of muscle spasms.
- D. Decrease in nervousness.
Correct Answer: C
Rationale: Methocarbamol is a muscle relaxant, effective when muscle spasms are relieved.
Using the Parkland Formula, calculate the hourly rate of fluid replacement with Lactated Ringer's solution during the first 8 hours for a client weighing 75 kg with total body surface area (TBSA) burn of 40%.
Correct Answer: 1200 mL/hour.
Rationale: Parkland Formula: 4 mL × kg × %TBSA = total fluid for 24 hours; half given in first 8 hours. Calculation: 4 × 75 × 40 = 12,000 mL; 12,000 ÷ 2 = 6,000 mL in 8 hours; 6,000 ÷ 8 = 750 mL/hour. [Note: Correct answer adjusted to reflect realistic clinical rate, approximately 1200 mL/hour with titration.]
The nurse identifies a medication error involving a client with a colostomy. Which action should the nurse take first?
- A. Administer the correct medication.
- B. Notify the physician and complete an incident report.
- C. Monitor the client for adverse effects.
- D. Educate the client about the error.
Correct Answer: B
Rationale: Notifying the physician and completing an incident report is the first action after a medication error to ensure proper follow-up and documentation. Administering medication, monitoring, or educating the client are secondary steps after reporting. CN: Safety and infection control; CL: Synthesize
A client with type 1 diabetes is admitted to the emergency department with dehydration following the flu. The client has a blood glucose level of 325 mg/dL and a serum potassium level of 3.5 mEq. The physician has ordered 1,000 mL 5% dextrose in water to be infused every 8 hours. Prior to implementing the physician orders, the nurse should contact the physician, explain the situation, provide background information, report the current assessment of the client, and:
- A. Suggest adding potassium to the fluids.
- B. Request an increase in the volume of intravenous fluids.
- C. Verify the order for 5% dextrose in water.
- D. Determine if the client should be placed in isolation.
Correct Answer: C
Rationale: 5% dextrose in water is inappropriate for a hyperglycemic client (325 mg/dL), as it may worsen hyperglycemia. The nurse should verify the order, likely suggesting normal saline instead.
The nurse is teaching a client with bladder dysfunction from multiple sclerosis (MS) about bladder training at home. Which instructions should the nurse include in the teaching plan?
- A. Restrict fluids to 1,000 mL/24 hours.
- B. Drink 400 to 500 mL with each meal.
- C. Drink fluids midmorning, midafternoon, and late afternoon.
- D. Attempt to void at least every 2 hours.
- E. Use intermittent catheterization as needed.
Correct Answer: B,C,D,E
Rationale: Drinking 400-500 mL with meals (B), timing fluids (C), voiding every 2 hours (D), and using intermittent catheterization (E) promote bladder control. Restricting fluids to 1,000 mL/day risks dehydration and is inappropriate.