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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This statement is judgmental and discouraging. It implies that the client is not making enough effort and does not acknowledge the possible challenges or barriers that the client may face.
Choice B reason: This statement is accusatory and confrontational. It puts the blame on the client and does not offer any support or guidance.
Choice C reason: This statement is empathetic and supportive. It shows that the nurse is interested in the client's situation and wants to help them identify and overcome any obstacles that may have affected their weight loss.
Choice D reason: This statement is unrealistic and dismissive. It does not address the reasons for the weight gain and does not help the client learn from their experience. It also ignores the emotional impact of the setback.
Correct Answer is D
Explanation
Choice A reason: This is an important action, but not the first one. The nurse should provide oxygen after lowering the client to the floor and protecting the head, to improve the oxygenation and prevent hypoxia.
Choice B reason: This is an important action, but not the first one. The nurse should turn the client onto his side after lowering the client to the floor and protecting the head, to prevent aspiration and maintain a patent airway.
Choice C reason: This is a helpful action, but not the first one. The nurse should provide privacy after lowering the client to the floor and protecting the head, to respect the client's dignity and reduce the stimulation.
Choice D reason: This is the first action, because lowering the client to the floor and protecting the head can prevent injury and trauma to the client during the seizure. The nurse should use a pillow, blanket, or towel to cushion the head, and move any furniture or objects away from the client.
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