A nurse is preparing to administer timolol eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take?

Instruct the client to blink several times after instillation of the medication.

Ask the client to look straight ahead during instillation of the medication.

Apply pressure to the bridge of the nose after instillation of the medication.

Place each drop of the medication directly on to the client's cornea.

Answer and Explanation

The Correct Answer is C

Choice A reason: This is an incorrect action, because instructing the client to blink several times after instillation of the medication can cause the medication to drain out of the eye and reduce its effectiveness.

Choice B reason: This is a correct action, but not the best one. Asking the client to look straight ahead during instillation of the medication can help the nurse to aim the drop accurately and avoid touching the eye with the dropper.

Choice C reason: This is the best action, because applying pressure to the bridge of the nose after instillation of the medication can prevent the medication from entering the systemic circulation and causing adverse effects, such as bradycardia, hypotension, or bronchospasm.

Choice D reason: This is an incorrect action, because placing each drop of the medication directly on to the client's cornea can cause irritation, injury, or infection to the eye. The medication should be placed in the lower conjunctival sac of the eye.

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Correct Answer is B

Explanation

Choice A reason: This is an incorrect route, because maternal-fetal transmission of hepatitis A is very rare and occurs only if the mother has acute hepatitis A during the third trimester of pregnancy.

Choice B reason: This is the correct route, because fecal-oral contamination of hepatitis A is the most common mode of transmission. Hepatitis A is a viral infection that affects the liver and is spread through ingestion of contaminated food or water, or contact with infected feces.

Choice C reason: This is an incorrect route, because genital sexual contact of hepatitis A is uncommon and occurs only if there is oral-anal contact with an infected person.

Choice D reason: This is an incorrect route, because blood to blood transmission of hepatitis A is also uncommon and occurs only if there is exposure to infected blood or blood products, such as through needle sharing or transfusion.

A. Have the client gently blow clots from his nose every 5 min B. Instruct the client to sit with his head hyperextended C. Apply ice compresses to the back of the client’s neck D. Pinch the soft portion of the client’s nose for 10 min

Correct Answer is D

Explanation

Choice A reason: Having the client gently blow clots from his nose every 5 min is an incorrect action, because it can increase the bleeding and trauma to the nasal mucosa. The client should avoid blowing or picking his nose.

Choice B reason: Instructing the client to sit with his head hyperextended is an incorrect action, because it can cause the blood to drain into the throat and increase the risk of aspiration or vomiting. The client should sit with his head tilted forward.

Choice C reason: Applying ice compresses to the back of the client’s neck is an incorrect action, because it has no effect on the bleeding site. The nurse should apply ice compresses to the bridge of the nose or the cheeks to constrict the blood vessels and reduce the bleeding.

Choice D reason: Pinching the soft portion of the client’s nose for 10 min is a correct action, because it applies direct pressure to the bleeding site and allows clot formation. The nurse should instruct the client to breathe through his mouth and avoid swallowing the blood.

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A nurse is preparing to administer timolol eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take?

Nursing Test Bank

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