When administering a patients eye drops, the nurse recognizes the need to prevent absorption by the nasolacrimal duct. How can the nurse best achieve this goal?
- A. Ensure that the patient is well hydrated at all times.
- B. Encourage self-administration of eye drops.
- C. Occlude the puncta after applying the medication.
- D. Position the patient supine before administering eye drops.
Correct Answer: C
Rationale: The correct answer is C: Occlude the puncta after applying the medication. By occluding the puncta after applying the eye drops, the nurse can prevent the medication from draining into the nasolacrimal duct and being absorbed systemically. This is important to ensure that the medication remains in the eye and exerts its intended local effect.
Choice A (Ensure that the patient is well hydrated at all times) is incorrect because hydration status does not directly prevent absorption through the nasolacrimal duct.
Choice B (Encourage self-administration of eye drops) is incorrect as the method of administration does not prevent absorption through the nasolacrimal duct.
Choice D (Position the patient supine before administering eye drops) is incorrect as it does not address the specific issue of preventing absorption through the nasolacrimal duct.
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A patient has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the patient should be kept in a prone position until otherwise ordered. What should the nurse do?
- A. Call the physician and ask for the order to be confirmed.
- B. Follow the order because this position will help keep the retinal repair intact.
- C. Instruct the patient to maintain this position to prevent bleeding.
- D. Reposition the patient after the first dressing change.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Prone position post retinal detachment repair helps the gas bubble or silicone oil stay against the retina to support healing.
2. This position prevents the bubble/oil from moving and causing further detachment.
3. Repositioning can jeopardize the surgical repair and lead to complications.
4. Calling the physician (A) is unnecessary as the order is clear.
5. Instructing the patient to prevent bleeding (C) is not related to the positioning after retinal detachment repair.
6. Repositioning after the first dressing change (D) contradicts the initial order and risks complications.
A woman scheduled for a simple mastectomy in one week is having her preoperative education provided by the clinic nurse. What educational intervention will be of primary importance to prevent hemorrhage in the postoperative period?
- A. Limit her intake of green leafy vegetables.
- B. Increase her water intake to 8 glasses per day.
- C. Stop taking aspirin.
- D. Have nothing by mouth for 6 hours before surgery.
Correct Answer: C
Rationale: The correct answer is C: Stop taking aspirin. Aspirin is a blood thinner that can increase the risk of bleeding during and after surgery. By stopping aspirin before surgery, the woman's blood clotting ability will improve, reducing the risk of hemorrhage.
A: Limiting intake of green leafy vegetables is not directly related to preventing hemorrhage in the postoperative period.
B: Increasing water intake is important for overall health, but it does not specifically address the risk of hemorrhage related to aspirin use.
D: Having nothing by mouth for 6 hours before surgery is important for preventing aspiration during anesthesia, but it does not directly address the risk of hemorrhage related to aspirin use.
A patient diagnosed with Bells palsy is having decreased sensitivity to touch of the involved nerve. What should the nurse recommend to prevent atrophy of the muscles?
- A. Blowing up balloons
- B. Deliberately frowning
- C. Smiling repeatedly
- D. Whistling
Correct Answer: A
Rationale: The correct answer is A: Blowing up balloons. Blowing up balloons involves the activation of the facial muscles, which helps prevent muscle atrophy in patients with Bell's palsy. This exercise promotes muscle strength and prevents weakness. Deliberately frowning (B), smiling repeatedly (C), and whistling (D) do not specifically target the facial muscles involved in Bell's palsy and may not be as effective in preventing muscle atrophy.
A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a patients plan of care. The presence of what chronic health problem would most likely prompt this diagnosis?
- A. Herpes simplex
- B. HIV
- C. Spina bifida
- D. Hypogammaglobulinemia
Correct Answer: D
Rationale: The correct answer is D: Hypogammaglobulinemia. This chronic health problem predisposes individuals to latex allergies due to reduced levels of immunoglobulins, increasing susceptibility to allergic reactions. Latex contains proteins that can trigger immune responses in individuals with compromised immune systems.
Choice A: Herpes simplex is a viral infection and does not directly relate to latex allergies.
Choice B: HIV weakens the immune system but is not specifically associated with latex allergies.
Choice C: Spina bifida is a congenital condition affecting the spinal cord and does not directly impact the likelihood of latex allergies.
A 45-year-old woman has just undergone a radical hysterectomy for invasive cervical cancer. Prior to the surgery the physician explained to the patient that after the surgery a source of radiation would be placed near the tumor site to aid in reducing recurrence. What is the placement of the source of radiation called?
- A. Internal beam radiation
- B. Trachelectomy
- C. Brachytherapy
- D. External radiation
Correct Answer: C
Rationale: The correct answer is C: Brachytherapy. Brachytherapy involves placing a radiation source near or directly into the tumor site. In this case, after the hysterectomy, the source of radiation is placed near the cervical cancer site to deliver targeted radiation therapy. This method helps reduce the risk of cancer recurrence by delivering high doses of radiation to the tumor while minimizing exposure to surrounding healthy tissues.
Choice A (Internal beam radiation) typically refers to a type of external radiation therapy where radiation beams are directed at the tumor from outside the body, not placed internally like brachytherapy.
Choice B (Trachelectomy) is a surgical procedure that involves removal of the cervix while preserving the uterus, not related to radiation therapy.
Choice D (External radiation) involves delivering radiation from outside the body using a machine, unlike brachytherapy where the radiation source is placed internally near the tumor site.