Nokea
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 student nurse is caring for a patient who has undergone a wide excision of the vulva. The student should know that what action is contraindicated in the immediate postoperative period?
- A. Placing patient in low Fowlers position
- B. Application of compression stockings
- C. Ambulation to a chair
- D. Provision of a low-residue diet
Correct Answer: B
Rationale: The correct answer is B: Application of compression stockings. Immediately after a wide excision of the vulva, compression stockings should be avoided as they can increase the risk of blood clots. Placing the patient in a low Fowler's position helps with comfort and promotes healing. Ambulation to a chair aids in preventing complications like pneumonia and deep vein thrombosis. Providing a low-residue diet is appropriate postoperatively to prevent straining during bowel movements.
A patient with genital herpes is having an acute exacerbation. What medication would the nurse expect to be ordered to suppress the symptoms and shorten the course of the infection?
- A. Clotrimazole (Gyne-Lotrimin)
- B. Metronidazole (Flagyl)
- C. Podophyllin (Podofin)
- D. Acyclovir (Zovirax)
Correct Answer: D
Rationale: The correct answer is D: Acyclovir (Zovirax). Acyclovir is an antiviral medication specifically used to treat herpes infections, including genital herpes. It works by inhibiting the replication of the herpes virus, thereby suppressing symptoms and shortening the course of the infection. Clotrimazole (A) is an antifungal medication used to treat yeast infections, not effective against viral infections like herpes. Metronidazole (B) is an antibiotic used to treat bacterial infections, not effective against viruses. Podophyllin (C) is a topical treatment for genital warts caused by the human papillomavirus (HPV), not effective for herpes. Therefore, the correct choice is Acyclovir (D) for treating genital herpes exacerbation.
A patient is scheduled to have an electronystagmography as part of a diagnostic workup for Mnires disease. What question is it most important for the nurse to ask the patient in preparation for this test?
- A. Have you ever experienced claustrophobia or feelings of anxiety while in enclosed spaces?
- B. Do you currently take any tranquilizers or stimulants on a regular basis?
- C. Do you have a history of falls or problems with loss of balance?
- D. Do you have a history of either high or low blood pressure?
Correct Answer: A
Rationale: The correct answer is A: Have you ever experienced claustrophobia or feelings of anxiety while in enclosed spaces? This question is important because electronystagmography involves the patient being placed in a confined space with sensors attached to monitor eye movements. Claustrophobia or anxiety can significantly impact the patient's ability to tolerate the test, affecting its accuracy.
Choice B: Do you currently take any tranquilizers or stimulants on a regular basis? While relevant in some cases, it is not as crucial as ensuring the patient can tolerate the test environment.
Choice C: Do you have a history of falls or problems with loss of balance? While relevant to Mnire's disease, it is not directly related to the preparation for electronystagmography.
Choice D: Do you have a history of either high or low blood pressure? While monitoring blood pressure is important for some procedures, it is not a primary concern for electronystagmography.
Which of the following nursing interventions would most likely facilitate effective communication with a hearing-impaired patient?
- A. Ask the patient to repeat what was said in order to evaluate understanding.
- B. Stand directly in front of the patient to facilitate lip reading.
- C. Reduce environmental noise and distractions before communicating.
- D. Raise the voice to project sound at a higher frequency.
Correct Answer: C
Rationale: The correct answer is C: Reduce environmental noise and distractions before communicating. This intervention is most likely to facilitate effective communication with a hearing-impaired patient because it creates an optimal environment for the patient to better focus on the communication. By reducing noise and distractions, the patient can more easily concentrate on the conversation and lip reading, if needed. This approach demonstrates sensitivity to the patient's needs and enhances the chances of successful communication.
The other choices are incorrect because:
A: Asking the patient to repeat what was said may cause frustration and does not address the environmental factors that can hinder communication.
B: Standing directly in front of the patient to facilitate lip reading may help, but it does not address the impact of environmental noise and distractions on communication.
D: Raising the voice to project sound at a higher frequency is not effective as it can distort speech and may not necessarily improve understanding for a hearing-impaired patient.
A patient is receiving opioids for pain. Which bowel assessment is a priority?
- A. Clostridium difficile
- B. Constipation
- C. Hemorrhoids
- D. Diarrhea
Correct Answer: B
Rationale: The correct answer is B: Constipation. When a patient is receiving opioids, constipation is a common side effect due to decreased gut motility. It is a priority assessment because untreated constipation can lead to serious complications such as bowel obstruction. Monitoring for constipation allows for early intervention with stool softeners or laxatives to prevent complications.
Incorrect choices:
A: Clostridium difficile - While important to consider in patients on antibiotics, it is not directly related to opioid use.
C: Hemorrhoids - Although opioids can contribute to constipation which may exacerbate hemorrhoids, it is not the priority assessment.
D: Diarrhea - Opioids typically cause constipation, so diarrhea is less likely to be a priority concern in this scenario.