A nurse is administering multiple types of ophthalmic drops to a client. Which of the following actions should the nurse take?
Hold the dropper 3 cm (1.2 in) away from the client's eye.
Massage the client's eyelids for 20 seconds after instillation.
Wait 5 min between the administration of each medication.
Ask the client to close their eyes tightly after instilling each medication.
The Correct Answer is C
A. The dropper should be held about 1 cm (0.4 in) away from the eye to avoid touching or injuring the eye or contaminating the dropper tip.
B. Massaging the eyelids after instillation is not a standard practice and may cause discomfort or injury to the eye.
C. Administering multiple ophthalmic medications requires a sufficient interval between doses to prevent interactions and ensure effectiveness.
D. Asking the client to close their eyes tightly may squeeze out some of the medication or increase intraocular pressure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This gait involves both crutches advancing simultaneously followed by both legs.
B. This gait involves swinging both legs and crutches forward at the same time.
C. This gait involves alternating movement of each crutch and leg, providing more stability but may be difficult for a client with limited weight-bearing on one leg.
D. In this gait, the client advances both crutches and the affected leg simultaneously, followed by the unaffected leg.
Correct Answer is A
Explanation
A. At 6 hours postoperative, difficulty voiding is common due to anesthesia effects and pain. The nurse should begin with noninvasive measures to stimulate urination. Hearing running water can help trigger the micturition reflex and promote voiding safely.
B. Lying supine may make it more difficult for the client to void. Sitting upright or ambulating to the bathroom may be more effective.
C. This is inadequate fluid intake; normal intake is usually 2,000–3,000 mL/day unless restricted.Furthermore,this does not directly address the immediate difficulty voiding.
D. Catheterization should be considered only after other interventions to promote voiding have been attempted and failed, as it carries the risk of infection and discomfort.
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