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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A 68-year-old woman is brought to the emergency room by ambulance. She was found by her husband slumped in her chair and unresponsive. Tentative diagnosis is cerebrovascular accident (CVA). The physician orders a 15% solution of mannitol IV. The nurse knows that this drug is given for what purpose?
- A. To increase urine output
- B. To dissolve clots
- C. To reduce blood pressure
- D. To decrease muscle spasms
Correct Answer: C
Rationale: Mannitol reduces intracranial pressure and blood pressure by promoting diuresis in CVA patients with cerebral edema.
The nurse is planning the care of the client with Meniere's disease. With which member of the interdisciplinary team should the nurse expect a consultation?
- A. Rheumatologist
- B. Otolaryngologist
- C. Physical therapist
- D. Oncologist
Correct Answer: B
Rationale: Since Meniere's disease is a condition of the ear, the nurse would plan to include the otolaryngologist. Rheumatologists, physical therapists, and oncologists treat unrelated conditions.
The nurse speaks with the client who recently learned that cataracts are developing in both of the client's eyes. Which statement made by the client should the nurse correct?
- A. It is important that I schedule my surgery as soon as possible.
- B. Usually surgery is performed on each eye at different times.
- C. My own lens will be removed when I have cataract surgery.
- D. An intraocular lens may be inserted with the surgical procedure.
Correct Answer: A
Rationale: Although there is reduced vision with beginning cataract development, a person can wait until vision worsens before having surgery. When vision is reduced to the extent that ADLs are affected, surgery should be performed as soon as possible. If both eyes have cataracts, usually the eyes are treated in separate procedures. Surgery for a cataract involves removal of the client's lens, and in most situations, the lens is replaced with an intraocular lens.
The student nurse asks the nurse, 'Which type of hearing loss involves damage to the cochlea or vestibulocochlear nerve?' Which statement is the best response of the nurse?
- A. It is called conductive hearing loss.
- B. It is called a functional hearing loss.
- C. It is called a mixed hearing loss.
- D. It is called sensorineural hearing loss.
Correct Answer: D
Rationale: Sensorineural hearing loss involves cochlear or vestibulocochlear nerve damage. Conductive loss affects the outer/middle ear, functional loss is psychological, and mixed involves both.
Which statement by the daughter of an 80-year-old female client who lives alone warrants immediate intervention by the nurse?
- A. I put a night-light in my mother’s bedroom.
- B. I got carbon monoxide detectors for my mother’s house.
- C. I changed my mother’s furniture around.
- D. I got my mother large-print books.
Correct Answer: C
Rationale: Changing furniture increases fall risk in an elderly client with potential sensory deficits, requiring intervention. Night-lights, CO detectors, and large-print books enhance safety.