A nurse is preparing to administer eye drops to a client. Which of the following nursing actions is appropriate?

Have the client tilt her head slightly so that the medication enters the nasolacrimal duct.

Gently wash away any exudate along the eyelid margin from the outside towards the inner canthus.

Use aseptic technique and drop the medication into the conjunctival sac.

Drop prescribed number of drops onto the cornea.

Answer and Explanation

The Correct Answer is C

A. Tilted head position facilitates drainage into the nasolacrimal duct, not necessarily into the eye.

B. Washing away exudate is not necessary before administering eye drops.

C. Using aseptic technique to drop medication into the conjunctival sac ensures proper delivery of the medication to the eye.

D. Dropping medication onto the cornea can cause discomfort and may not effectively reach the eye.

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Correct Answer is D

Explanation

A. Prohibiting visitors is not necessary for clients with sealed internal radiation implants. Visitors should be allowed unless specific restrictions are required based on the type of radiation therapy.

B. While maintaining distance from the radiation source is important, there is no specific guideline stating a 3-foot distance. The nurse should follow institutional policies and radiation safety guidelines regarding proximity to the radiation source.

C. There is no need to maintain the client on bed rest for 72 hours after receiving a sealed

internal radiation device. The client should be encouraged to ambulate and perform activities of daily living as tolerated.

D. Requiring the client to wear a dosimeter badge allows healthcare providers to monitor the amount of radiation exposure received by the client and ensures that radiation safety protocols are followed.

A. A client who has chronic obstructive pulmonary disease and needs guidance on incentive spirometry B. A client who had a myocardial infarction 3 days ago and reports chest discomfort C. A client who had a stroke 2 days ago and needs help toileting D. A client who has awoken following a bronchoscopy and requests a drink

Correct Answer is C

Explanation

A. Providing guidance on incentive spirometry requires specialized knowledge and skill that should be provided by a licensed healthcare provider, such as a nurse.

B. A client who had a myocardial infarction 3 days ago and reports chest discomfort requires ongoing assessment and monitoring by a licensed healthcare provider, such as a nurse, due to the potential for cardiac complications.

C. Assisting a client who had a stroke 2 days ago and needs help toileting is a task that can be safely delegated to an assistive personnel, as long as the client's condition is stable and the assistive personnel has been trained in providing basic care.

D. Providing a drink to a client who has awoken following a bronchoscopy may require assessment and monitoring for potential complications, such as aspiration or respiratory distress, which should be provided by a licensed healthcare provider, such as a nurse.

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A nurse is preparing to administer eye drops to a client. Which of the following nursing actions is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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