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.
The Correct Answer is B,D,C,A
Rationale:
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.
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.
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Position the child at a 10° to 20° angle after feeding: This angle is too low to effectively reduce the risk of aspiration. The child should remain in at least a 30° to 45° upright position during and after feeding for optimal safety.
B. Measure the tubing from the nose to the distal port: Correct placement measurement involves determining the appropriate tube length from the tip of the nose to the earlobe and then to the xiphoid process. Measuring to the distal port ensures accurate placement for safe feeding.
C. Warm the formula in the microwave: Microwaving can create uneven heating and hot spots that may burn the gastrointestinal mucosa. Formula should be warmed by placing the container in warm water and checking the temperature before administration.
D. Complete the feeding in 5 min: Rapid feeding increases the risk of nausea, vomiting, and aspiration. Feedings should be administered slowly over the recommended time frame to allow for tolerance and digestion.
Correct Answer is A
Explanation
A. "A living will is a document that includes my wishes about health care decisions.": A living will is an advance directive that specifies a client’s preferences for medical treatment in situations where they are unable to communicate.
B. "My partner needs to be present as a witness when I sign a living will.": Witness requirements vary by state, and typically a neutral adult, not necessarily a partner, must witness the signing.
C. "My provider will make my health care decisions if I complete advance directives.": Advance directives are intended to communicate the client’s own wishes, not delegate decision-making solely to the provider. The provider’s role is to follow the client’s documented preferences.
D. "Advance directives outline who inherits my material possessions in the event of my death.": Inheritance is addressed in a will, not advance directives. Advance directives focus exclusively on medical and end-of-life care decisions.
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