Nokea
The nurse has taught the parent of a 6-year-old client with bacterial conjunctivitis how to administer ophthalmic medications. Which of the following statements by the parent would indicate a correct understanding of the teaching?
- A. My child should look down at the floor while I administer the eye drops.
- B. My child should squeeze the eyes closed after I administer the eye drops.
- C. I will apply firm pressure to my child's eyes after I administer the eye ointment
- D. I will apply the eye ointment along my child's lower eyelids starting at the inner corner of the eyes
Correct Answer: D
Rationale: Appropriate administration of ophthalmic medications (eg, eye drops, ointments) protects eye structures and ensures appropriate distribution across the eye. Ophthalmic ointment should be administered along the lower eyelid, moving from the inner canthus to the outer canthus (inner corner to outer corner) (Option 4). In addition, the medication package (eg, eye dropper, tube of ointment) must not touch the eyes to prevent contamination.
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The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring?
- A. Auscultate breath sounds to assess for crackles
- B. Monitor for >50 mL/hr urine output
- C. Monitor Glasgow Coma Scale increasing from 8/15 to 9/15
- D. Press over the tibia to assess for pitting edema
Correct Answer: D
Rationale: Pitting edema indicates fluid overload, a potential mannitol complication due to fluid shifts. High urine output is expected, and improving Glasgow Coma Scale is a therapeutic effect.
When monitoring an infant with a left-to-right sided heart shunt, which findings would the nurse expect during the physical assessment? Select all that apply.
- A. Clubbing of fingertips
- B. Cyanosis when crying
- C. Diaphoresis during feedings
- D. Heart murmur
- E. Poor weight gain
Correct Answer: C,D,E
Rationale: Left-to-right shunts (e.g., VSD) cause pulmonary overcirculation, leading to diaphoresis, murmurs, and poor weight gain. Clubbing and cyanosis are more typical of right-to-left shunts.
The RN charge nurse hands the LPN/LVN a syringe filled with medication that the RN has just drawn and asks the LPN/LVN to administer this to a client. How should the LPN/LVN respond?
- A. Do as requested by the charge nurse
- B. Ask the charge nurse what the medication is and then administer it
- C. Ask the charge nurse what the medication is, check the order, and then administer it
- D. Refuse to administer the medication
Correct Answer: C
Rationale: Verifying the medication and checking the order ensures safe administration, adhering to medication safety protocols. Blind administration or refusal is unsafe or uncooperative.
The client has an IV in place when he returns for surgery. While examining the IV site, the licensed practical nurse notices pallor, coolness, and edema. The nurse is aware that these are signs of:
- A. Infiltration
- B. Infection
- C. Thrombus formation
- D. Sclerosing of the vein
Correct Answer: A
Rationale: Pallor, coolness, and edema at an IV site indicate infiltration, where IV fluid leaks into surrounding tissue. Infection shows redness and warmth, thrombus formation may cause pain and redness, and sclerosing involves vein hardening, not edema.
A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?
- A. Place the child in the nearest bed
- B. Administer IV medication to slow down the seizure
- C. Place a padded tongue blade in the child's mouth
- D. Remove the child's toys from the immediate area
Correct Answer: D
Rationale: Remove the child's toys from the immediate area. Nursing care for a child having a seizure includes, maintaining airway patency, ensuring safety, administering medications, and providing emotional support. Since the seizure has already started, nothing should be forced into the child's mouth and the child should not be moved. Of the choices given, the first priority would be to provide a safe environment.