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The nurse is administering eye drops to a client. Which action is correct?
- A. Ask the client to report any blurring of vision and difficulty focusing that occurs after the administration of eye drops.
- B. Apply gentle pressure to the nasolacrimal canal for one to two minutes after instillation to prevent systemic absorption.
- C. Have the client lie down with eyes closed for 45 minutes after giving drops.
- D. Gently pull the lower lid down and place medicine in the center of the eye.
Correct Answer: B
Rationale: Applying pressure to the nasolacrimal canal prevents systemic absorption of eye drops, enhancing safety and efficacy.
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The nurse is concerned that the Caucasian client experiencing a stroke may have impaired hearing. Which observations of the client's behavior prompted this concern? Select all that apply.
- A. Nods and agrees to all statements made by the nurse
- B. Asks for more information about the therapy schedule
- C. Slow to respond verbally but answers questions appropriately
- D. Speaks in an excessively loud tone of voice
- E. Leans in toward the nurse when the nurse speaks
Correct Answer: A,D,E
Rationale: Nodding and agreeing to all statements, speaking loudly, and leaning toward the speaker suggest hearing impairment. Asking for schedule details and slow but appropriate responses do not indicate hearing issues.
The client with severe otitis media and mastoiditis is prescribed levofloxacin IV, 250 mg every 12 hours. The medication is diluted in 100 mL of NS. To deliver the antibiotic in 30 minutes, the nurse must infuse the solution at a rate of how many mL per hour?
- A. 200
Correct Answer: A
Rationale: The rate of IV infusion is calculated as follows: 100 mL over 30 minutes equals X mL over 60 minutes. Thus, 100/30 = X/60, so X = (100 × 60) / 30 = 200 mL/hr.
Which behavior by the male client should make the nurse suspect the client has a hearing loss? Select all that apply.
- A. The client reports hearing voices in his head.
- B. The client becomes irritable very easily.
- C. The client has difficulty making decisions.
- D. The client’s wife reports he ignores her.
- E. The client does not dominate a conversation.
Correct Answer: B,D,E
Rationale: Irritability, ignoring others, and not dominating conversations suggest hearing loss due to social withdrawal or misunderstanding. Hearing voices is psychiatric, and decision-making is unrelated.
The client is diagnosed with glaucoma. Which symptom should the nurse expect the client to report?
- A. Loss of peripheral vision.
- B. Floating spots in the vision.
- C. A yellow haze around everything.
- D. A curtain coming across vision.
Correct Answer: A
Rationale: Glaucoma causes loss of peripheral vision due to optic nerve damage from increased intraocular pressure. Floaters suggest vitreous issues, yellow haze is unrelated, and a curtain indicates retinal detachment.
The nurse is caring for a client who has recently had a cerebrovascular accident (CVA). When positioning the client and supporting her extremities, the nurse must remember that when voluntary control of muscles is lost:
- A. the feet will maintain a position of eversion.
- B. the upper extremities will rotate externally.
- C. the hip joint will rotate internally.
- D. flexor muscles will become stronger than extensors.
Correct Answer: D
Rationale: After a CVA, flexor muscles become stronger than extensors, leading to flexion contractures, requiring careful positioning to prevent deformities.