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 D
Explanation
A. The client is allergic to penicillin: Medication allergies are critical for the nurse and prescriber to know, but they are not directly relevant to occupational therapy planning.
B. The client's parent is in a skilled nursing facility: While this may influence social support, it is not directly relevant to the client’s rehabilitation needs or adaptive strategies for activities of daily living.
C. The client has two small children at home: Knowing family responsibilities can help plan overall care, but the specific home environment is more critical for occupational therapy interventions.
D. The client lives in a two-story home: The home environment, including stairs, affects mobility, accessibility, and safety after amputation. Reporting this information is essential for planning adaptive equipment, home modifications, and safe discharge.
Correct Answer is D
Explanation
Rationale:
A. Asks the client what her plans are for follow-up care: This is an appropriate action that demonstrates concern for the client’s continuity of care and safety, even if she decides to leave against medical advice.
B. Asks the client to sign a form releasing the hospital from legal responsibility: This is standard practice when a client leaves against medical advice, as it documents that the client was informed of potential risks and chose to leave voluntarily.This action is appropriate and does not require the charge nurse to intervene.
C. Shows the client her abnormal laboratory results: Providing relevant medical information is appropriate to help the client make an informed decision about her care before leaving the facility.
D. Asks security to detain the client until the provider is notified: Clients have the legal right to leave a healthcare facility unless they are under specific legal or mental health holds. Detaining a competent adult against their will is unlawful and violates patient rights hence requiring intervention by the charge nurse.
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