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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. "Reporting the incident to Adult Protective Services" is crucial when there are signs of elder abuse or neglect. This action ensures that appropriate interventions are initiated to protect the client.
B. "Interviewing the client with his adult child present" may not allow the client to speak freely, especially if the adult child is the perpetrator or involved in the abuse. Confidentiality and safety are essential considerations.
C. "Telling the client he must answer every assessment question" can be intimidating and may not facilitate open communication, especially in situations involving abuse.
D. "Advising the client to consult a social worker" may be appropriate after reporting the incident to Adult Protective Services, but it is not the initial action to take when abuse is suspected. Reporting to authorities is the priority to ensure the client's safety.
Correct Answer is A
Explanation
A.
A. Infuse 0.9% sodium chloride IV - In the event of a hemolytic reaction, it's important to stop
the blood transfusion immediately and infuse normal saline to maintain intravascular volume and support renal perfusion.
B. Administer an antipyretic - While fever may occur with a hemolytic reaction, the priority is to stop the transfusion and provide supportive care with fluids.
C. Decrease the infusion rate to 75 mL/hr - Lowering the infusion rate is not appropriate when a hemolytic reaction occurs; stopping the transfusion is necessary.
D. Place the client in a left lateral position - Positioning changes will not address the hemolytic reaction; stopping the transfusion and providing supportive care are the priority.
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