A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Apply pressure to the lacrimal punctum.

Place the child in a sitting position.

Instill the drops of medication.

Pull the lower eyelid downward.

Answer and Explanation

The Correct Answer is B, D, C, A

Rationale:

A. Apply pressure to the lacrimal punctum: This step is performed last to prevent systemic absorption of the medication by blocking the nasolacrimal duct. Holding gentle pressure for about 1 minute helps maximize the local effect of the drops.

B. Place the child in a sitting position: Positioning the child upright or with the head slightly tilted back promotes comfort, stability, and proper visualization of the conjunctival sac for accurate drop placement.

C. Instill the drops of medication: Instillation should occur after exposing the conjunctival sac to ensure the medication reaches the target area. The dropper should not touch the eye to prevent contamination.

D. Pull the lower eyelid downward: This creates a conjunctival pocket that holds the medication and allows it to spread evenly over the eye surface without spilling.

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Correct Answer is C

Explanation

A. "Keep objects away from your center of gravity while lifting.": Lifting objects away from the body increases strain on the back and risks injury. Objects should be kept close to the body to reduce musculoskeletal stress.

B. "Keep your feet together to provide a tight base of support.": A narrow stance decreases stability and increases the risk of losing balance. Proper lifting requires a wide, stable base with feet shoulder-width apart.

C. "Tighten abdominal muscles to improve balance.": Engaging the core stabilizes the spine, maintains proper posture, and helps prevent back injuries during lifting. This is an important ergonomic technique.

D. "Bend at the waist when lifting objects from the floor.": Bending at the waist places excessive strain on the lower back. Proper lifting technique involves bending at the knees and hips while keeping the back straight.

A. Place the head of the client's bed flat with the client's legs extended. B. Apply butterfly strips to approximate the wound edges. C. Apply pressure directly to the wound for 15 min. D. Place a sterile, saline-soaked dressing on the wound.

Correct Answer is D

Explanation

Rationale:

A. Place the head of the client's bed flat with the client's legs extended: Positioning flat may increase tension on the abdominal incision, potentially worsening the dehiscence. A low Fowler’s position with knees slightly bent is preferred to reduce strain on the wound.

B. Apply butterfly strips to approximate the wound edges: Forcing the wound edges together could trap bacteria inside and increase the risk of infection. Dehiscence requires moist protection, not forced closure at the bedside.

C. Apply pressure directly to the wound for 15 min: Direct pressure is appropriate for active bleeding, not for dehiscence. Applying pressure could damage tissues further and does not address the need to protect exposed structures.

D. Place a sterile, saline-soaked dressing on the wound: A moist sterile dressing protects the wound from contamination, prevents the tissues from drying, and reduces the risk of infection while awaiting further surgical evaluation.

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A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An occupational health nurse is providing teaching to a group of factory workers about proper lifting techniques. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A nurse caring for a postoperative client removes the client's dressing and notes an area of dehiscence. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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