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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 client has an hordeolum of the left eye, which is painful. Which intervention, if prescribed, should the nurse implement?
- A. Apply an eye patch on the left eye.
- B. Insert miotic eye drops twice daily.
- C. Apply a warm compress four times daily.
- D. Administer an antibiotic intravenously.
Correct Answer: C
Rationale: Warm compresses are applied to promote drainage of the hordeolum. Patching is not indicated, miotic drops treat glaucoma, and IV antibiotics are unnecessary as topical antibiotics are used.
The client receives a prescription for sodium fluoride for otosclerosis and asks the nurse, 'What will this medication do for my ears?' Which response by the nurse is correct?
- A. Sodium fluoride prevents the breakdown of bone cells and hardens the bone in the ear.
- B. Sodium fluoride causes the breakdown of bone cells and softens the bone in the ear.
- C. Sodium fluoride blocks the effect of histamine and dries the fluid in the ear.
- D. Sodium fluoride causes the production of histamine and increases the fluid in the ear.
Correct Answer: A
Rationale: The medication, sodium fluoride, retards bone reabsorption (prevents the breakdown of bone cells) and promotes calcification (hardening) of the bony lesions in the ear.
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.
The client diagnosed with glaucoma is prescribed a miotic cholinergic medication. Which data indicate the medication has been effective?
- A. No redness or irritation of the eyes.
- B. A decrease in intraocular pressure.
- C. The pupil reacts briskly to light.
- D. The client denies any type of floaters.
Correct Answer: B
Rationale: Miotic cholinergics (e.g., pilocarpine) reduce intraocular pressure in glaucoma by increasing aqueous outflow. Redness, pupil reaction, and floaters are not primary indicators.
The nurse writes the diagnosis 'risk for injury related to impaired balance' for the client diagnosed with vertigo. Which nursing intervention should be included in the plan of care?
- A. Provide information about vertigo and its treatment.
- B. Assess for level and type of diversional activity.
- C. Assess for visual acuity and proprioceptive deficits.
- D. Refer the client to a support group and counseling.
Correct Answer: C
Rationale: Assessing visual and proprioceptive deficits identifies factors contributing to vertigo-related falls, enhancing safety. Information, activities, and referrals are secondary.