Nokea
The nurse is administering eyedrops to the client. Which guidelines should the nurse adhere to when instilling the drops into the eye? Select all that apply.
- A. Do not touch the tip of the medication container to the eye.
- B. Apply gentle pressure on the outer canthus of the eye.
- C. Apply sterile gloves prior to instilling eyedrops.
- D. Hold the lower lid down and instill drops into the conjunctiva.
- E. Gently pat the skin to absorb excess eyedrops on the cheek.
Correct Answer: A,D,E
Rationale: Avoiding container contact prevents contamination, instilling into the conjunctiva ensures absorption, and patting excess drops maintains hygiene. Pressure on the outer canthus is incorrect (nasolacrimal duct pressure prevents systemic absorption), and sterile gloves are unnecessary.
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The client is scheduled for laser-assisted in situ keratomileusis (LASIK) surgery for severe myopia. Which instruction should the nurse discuss prior to the client's discharge from day surgery?
- A. Wear bilateral eye patches for three (3) days.
- B. Wear corrective lenses until the follow-up visit.
- C. Do not read any material for at least one (1) week.
- D. Teach the client how to instill corticosteroid ophthalmic drops.
Correct Answer: D
Rationale: Corticosteroid drops reduce inflammation post-LASIK, requiring teaching. Eye patches are not used, corrective lenses are unnecessary, and reading restrictions are shorter.
Which risk factors should the nurse discuss with the client concerning reasons for hearing loss? Select all that apply.
- A. Perforation of the tympanic membrane.
- B. Chronic exposure to loud noises.
- C. Recurrent ear infections.
- D. Use of nephrotoxic medications.
- E. Multiple piercings in the auricle.
Correct Answer: A,B,C,D
Rationale: Tympanic perforation, loud noise, ear infections, and ototoxic medications (e.g., aminoglycosides) cause hearing loss. Auricle piercings are cosmetic and unrelated.
A 27-year-old woman is admitted to the hospital complaining of numbness in both legs, difficulty walking, and double vision of one week in duration. Multiple sclerosis is suspected. Orders include bed rest with bathroom privileges, brain scan, EEG, lumbar puncture, adrenocorticotropic hormone (ACTH) 40 units intramuscularly (IM) bid x 3 days, then 30 units IM bid x 3 days, then 20 units IM bid x 3 days; and passive range of motion (ROM) progressing to active ROM as tolerated. In planning care for this client, which activity is most important to include?
- A. Encouraging her to perform all care activities for herself
- B. Frequent ambulation to retain joint mobility
- C. Scheduling frequent rest periods between physical activity
- D. Feeding the client to reduce energy needs
Correct Answer: C
Rationale: Frequent rest periods are essential to manage fatigue, a common symptom in multiple sclerosis, while supporting activity as tolerated.
The client with glaucoma is prescribed pilocarpine hydrochloride 1% eye drops to both eyes four times per day. The nurse knows that this medication has which expected action?
- A. Increases the outflow of aqueous humor
- B. Improves vision in dimly lit environments
- C. Increases production of aqueous humor
- D. Increases ability of both pupils to dilate
Correct Answer: A
Rationale: Pilocarpine hydrochloride is a cholinergic agent used to treat glaucoma. It causes miosis (pupillary constriction), which then increases the angle of the channel in the anterior chamber of the eye. This improves the outflow of aqueous humor. It does not improve vision in dim light, increase aqueous humor production, or cause pupil dilation.
The client's daughter tells the nurse of frustration while communicating with her elderly mother who wears hearing aids. Which intervention should the nurse suggest to the client's daughter?
- A. Minimize oral communication to essential matters.
- B. Speak directly into her mother's better ear.
- C. Use exaggerated mouth expressions while speaking.
- D. Attract her mother's attention before speaking.
Correct Answer: D
Rationale: Attracting the client's attention improves communication by including the client fully from the start. Minimizing communication, speaking into the ear, or exaggerated expressions are less effective.