Nokea
Which actions by the unlicensed assistive personnel (UAP) warrant intervention by the nurse? (Select all that apply.)
- A. Holding the wet washcloth in the microwave
- B. Holding the cloth on the client using an Ace wrap
- C. Turning the cloth so it remains warm on the client
- D. Using a clean washcloth for the compress
- E. Washing the hands on entering the clients room
Correct Answer: A,B
Rationale: The washcloth should be warmed under running warm water, as microwaving it can lead to burns. Gentle pressure is used to hold the compress in place, not an Ace wrap. The other actions are correct.
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A client is taking timolol (Timoptic) eyedrops. The nurse assesses the clients pulse at 50 beats/min. What action by the nurse is best?
- A. Administer the eyedrops as ordered.
- B. Assess the client for excessive salivation.
- C. Assess the client for shortness of breath.
- D. Hold the eyedrops and notify the provider.
Correct Answer: D
Rationale: Timolol is a beta blocker that can slow the heart rate. A pulse of 50 beats/min warrants holding the eyedrops and notifying the provider. Excessive salivation and shortness of breath are not typically related to timolol.
A client asks why blindness occurred from glaucoma. What explanation by the nurse is best?
- A. Because eye pressure was too high, the tissue died.
- B. Glaucoma always leads to permanent blindness.
- C. The traumatic damage to your eye was too great.
- D. The infection occurs so quickly, it can be treated.
Correct Answer: A
Rationale: Glaucoma is caused when the intraocular pressure becomes too high and stays high long enough to cause tissue ischemia and death. At that point, vision loss is permanent. Glaucoma does not always cause blindness, trauma is not the most common cause, and glaucoma is not an infection.
A client use a corneal ulcer. What information provided by the client most indicates a potential barrier to home care?
- A. Chronic use of sleeping pills
- B. Impaired near vision
- C. Slightly shaking hands
- D. Use of contact lenses
Correct Answer: A
Rationale: Antibiotic eyedrops are often needed every hour for the first 24 hours for corneal ulceration. The client who uses sleeping pills may not wake up each hour or may awaken unable to perform this task. Impaired near vision and shaking hands can both make administration of eyedrops more difficult but are not the most likely barriers. Contact lenses should be discarded.
The nurse working in the ophthalmology clinic sees clients with eyelid and eye problems. What information should the nurse understand about these disorders? (Select all that apply.)
- A. A chalazion is an inflammation of an eyelid sebaceous gland.
- B. An ectropion is the eyelid turning outward.
- C. An entropion is the eyelid turning outward.
- D. A hordeolum is an infection of the eyelid sweat gland.
- E. Keratoconjunctivitis sicca is caused by drugs or diseases.
Correct Answer: A,D,E
Rationale: A chalazion is an inflammation of one of the sebaceous glands in the eyelid. A hordeolum is an infection of a sweat gland in the eyelid. Keratoconjunctivitis sicca can be caused by drugs or diseases. An ectropion is an outward turning and sagging eyelid, while an entropion is an inward turning of the eyelid.
A client is seen in the ophthalmology clinic with bacterial conjunctivitis. Which statements by the client indicate correct understanding? (Select all that apply.)
- A. I won't wipe my eyes with the same cloth and share my towel.
- B. Eye irrigation should be done with warm saline or water.
- C. I have been prescribed antibiotics for my infection.
- D. I won't touch the tip of the eyedrop bottle to my eye.
- E. When the infection is gone, I can wear my contacts again.
Correct Answer: C,D
Rationale: Bacterial conjunctivitis is very contagious, and re-infection or cross-contamination must be avoided. Not touching the eyedrop bottle tip to the eye and using prescribed antibiotics are correct actions. Sharing towels, improper irrigation, or premature contact lens use can worsen or spread the infection.