Nokea
The nurse is observing a student nurse administering ear drops to a 2-year-old. Which observation by the nurse would indicate correct technique?
- A. Holds the child's head up and extended
- B. Places the head in chin-tuck position
- C. Pulls the pinna down and back
- D. Irrigates the ear before administering medication
Correct Answer: C
Rationale: For children under 3, pulling the pinna down and back straightens the ear canal for proper ear drop administration.
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The nurse is teaching a client with a new diagnosis of glaucoma about eye drop administration. Which of the following instructions should the nurse include?
- A. Apply pressure to the inner canthus after instilling drops.
- B. Instill the drops directly onto the cornea.
- C. Shake the bottle vigorously before use.
- D. Store the drops in the refrigerator.
Correct Answer: A
Rationale: applying pressure to the inner canthus (nasolacrimal occlusion) prevents systemic absorption of the medication
Which of the following statements by a client with a seizure disorder who is taking topiramate (Topamax) indicates that the client has understood the nurse's instruction?
- A. I will take the medicine before going to bed.
- B. I will drink 8 to 10 ten-ounce glasses of water a day.
- C. I will eat plenty of fresh fruits.
- D. I must take the medicine with a meal or snack.
Correct Answer: B
Rationale: Topiramate increases the risk of kidney stones, so adequate hydration (8-10 glasses of water daily) is essential to prevent this complication.
The nurse is teaching a client with an orthotopic bladder replacement. The nurse should tell the client to:
- A. Place a gauze pad over the stoma
- B. Lie on her side while evacuating the pouch
- C. Bear down with each voiding
- D. Wear a well-fitting drainage bag
Correct Answer: D
Rationale: A well-fitting drainage bag is essential for managing an orthotopic bladder replacement.
The client with color blindness will most likely have problems distinguishing which of the following colors?
- A. Orange
- B. Violet
- C. Red
- D. White
Correct Answer: C
Rationale: Red-green color blindness is the most common type, making it difficult to distinguish red.
A 25-year-old male is brought to the emergency room with a piece of metal in his eye. The first action the nurse should take is:
- A. Use a magnet to remove the object.
- B. Rinse the eye thoroughly with saline.
- C. Cover both eyes with paper cups.
- D. Patch the affected eye.
Correct Answer: C
Rationale: Covering both eyes prevents eye movement, reducing further damage.