Nokea
The nurse is reinforcing instructions related to antibiotic eye drop administration to the parent of a 5-year-old with bacterial conjunctivitis. Which instruction is most important?
- A. Discard tissues used to blot excess medication from the eye immediately
- B. Have your child lie down before you instill the eye drops
- C. Use warm, moist compresses to remove crusting on eyelids
- D. Wash hands before and after eye drop instillation
Correct Answer: D
Rationale: Hand washing before and after eye drop administration is most important to prevent infection spread in bacterial conjunctivitis. Discarding tissues , lying down , and using compresses are supportive but secondary to infection control.
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The nurse notes all of the following. Which should be attended to first?
- A. A blind client is calling out stating that she cannot find the call bell.
- B. There is a water spill on the floor near the bed of an elderly client who ambulates regularly.
- C. A postoperative client is asking for pain medication.
- D. A diabetic client is asking for a glass of water.
Correct Answer: B
Rationale: A water spill near an ambulatory elderly client's bed poses an immediate fall risk, requiring prompt attention to ensure safety. Call bell access, pain, or water requests are less critical.
Laboratory Reference Range
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L)
The nurse has received information from unlicensed assistive personnel about assigned client situations. Which of the following situations should the nurse address first?
- A. Client who has type 1 diabetes mellitus and a fasting capillary blood glucose level of 90 mg/dL (5.0 mmol/L)
- B. client who is collecting a 24-hour urine specimen and discarded the last void by mistake
- C. client who is requesting clarification about the diagnostic procedure that is scheduled to begin in 4 hours
- D. client who was recently admitted to a room that has a full sharps disposal container on the wall
Correct Answer: D
Rationale: A full sharps container poses an immediate safety hazard and must be addressed first. Normal glucose , a discarded void , and procedure clarification are less urgent.
The nurse is caring for a client who is terminally ill. When the client dies, the nurse should:
- A. Pronounce the client dead and call the doctor.
- B. Contact the coroner.
- C. Tag the body prior to the funeral home notification.
- D. Request an autopsy.
Correct Answer: C
Rationale: Tagging the body ensures proper identification before transfer to the funeral home. Nurses do not pronounce death, coroner contact depends on policy, and autopsies are not routinely requested.
The nurse reinforces discharge instructions to a client who was hospitalized for deep venous thrombosis that has now resolved. Which instructions should the nurse include to prevent reoccurrence? Select all that apply.
- A. Do not travel by car or airplane for at least 3-4 weeks
- B. Drink plenty of fluids daily and limit caffeine and alcohol intake
- C. Elevate legs on a footstool when sitting and dorsiflex the feet often
- D. Resume the walking or swimming exercise program as soon as possible after getting home
- E. Sit in a cross-legged yoga position for 5-10 minutes as this benefits circulation
Correct Answer: B,C,D
Rationale: To prevent DVT recurrence: stay hydrated to reduce blood viscosity, elevate legs and dorsiflex to promote venous return, and resume exercise to enhance circulation. Travel restrictions are not absolute post-resolution, and cross-legged sitting impedes venous flow.
Diltiazem (Cardizem) 90 mg qid is prescribed for an adult who has angina. Which statement by the client indicates a need for further instruction?
- A. I will take the pills before meals and at bedtime.
- B. I will call my physician if the pain gets worse than it has been.
- C. If my heart rate is less than 70, I will not take the pill.
- D. I will get up slowly when I stand up.
Correct Answer: C
Rationale: Diltiazem is not typically withheld based on heart rate alone unless specified; this indicates a need for clarification on administration instructions.