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 C

Explanation

A. Holding the newborn in an en face position: This action promotes bonding between the mother and the newborn and is a positive interaction.

B. Asking the father to change the newborn's diaper: Involving the father in caregiving tasks fosters family involvement and bonding.

C. Viewing the newborn's actions to be uncooperative: This suggests a negative perception of the newborn's behavior, which could indicate potential issues with bonding or misunderstanding

infant cues, requiring the nurse's intervention.

D. Requesting the nurse take the newborn to the nursery so she can rest: While rest is important for the mother, separating the newborn from the mother could disrupt bonding and breastfeeding, so this action should be discussed further with the client to explore other options.

A. A client who has gastroenteritis and is lethargic and confused B. A client who has cystic fibrosis, has a thick, productive cough, and reports thirst C. A client who has sickle cell anemia and reports pain 15 minutes after receiving oral analgesic D. A client who has diabetes mellitus and has a morning fasting capillary glucose of 185 mg/dL

Correct Answer is A

Explanation

A. Gastroenteritis can lead to dehydration and electrolyte imbalances, which can cause lethargy and confusion. This indicates a potentially serious condition requiring immediate attention.

B. While cystic fibrosis requires management, the symptoms described (thick, productive cough and thirst) are not immediately life-threatening.

C. Sickle cell anemia pain is significant but may not require immediate intervention if the client has just received analgesia and is being monitored.

D. While a morning fasting capillary glucose of 185 mg/dL is elevated in a client with diabetes mellitus, it does not require immediate intervention unless accompanied by symptoms of hyperglycemia such as confusion or lethargy.

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