A nurse is preparing to administer timolol eye drops to a client who has glaucoma. In which order should the nurse perform the following steps? (place the steps , placing them in the order of performance.)
Verify the clarity and color of the eye drops.
Tilt the client's head backward toward the ceiling.
Pull the client's lower lid down with the nondominant hand.
Administer the prescribed number of drops.
Apply gentle pressure to the client's punctum.
Administer the prescribed number of drops
Apply gentle pressure to the client's punctum
Tilt the client's head backward toward the ceiling
Pull the client's lower lid down with the nondominant hand
Verify the clarity and color of the eye drops
The Correct Answer is E,C,D,A,B
- Verify the clarity and color of the eye drops. Ensuring the medication is not expired or contaminated is the first step in safe administration.
- Tilt the client's head backward toward the ceiling. This position helps prevent the drops from draining out of the eye.
- Pull the client's lower lid down with the nondominant hand. This creates a small pocket for the eye drops to be instilled properly.
- Administer the prescribed number of drops. The medication should be placed in the conjunctival sac, not directly on the cornea.
- Apply gentle pressure to the client's punctum. This prevents systemic absorption by blocking the nasolacrimal duct and reduces systemic side effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Antibiotic therapy. This is incorrect because there is no indication of an infection. The WBC count is within the normal range, and there are no symptoms suggestive of a bacterial infection.
B. Protective environment. This is incorrect because a protective environment is used for immunocompromised clients, such as those undergoing chemotherapy or with severe neutropenia, which is not the case here.
C. Blood transfusion. This is incorrect because although the hemoglobin level is low (8.1 g/dL), it is not critically low enough to require a transfusion. Instead, iron supplementation is the preferred treatment.
D. Iron supplementation. This is correct because the child’s hemoglobin and hematocrit levels indicate mild anemia, likely due to excessive cow’s milk intake, which can lead to iron deficiency anemia in toddlers. Iron supplementation will help correct the deficiency.
Correct Answer is A
Explanation
A. A child with cystic fibrosis and difficulty clearing secretions is the priority because airway clearance is critical in cystic fibrosis. Mucus buildup can lead to respiratory distress and infection, requiring immediate intervention.
B. A child with an atrial septal defect and a heart rate of 120/min is not the priority because a heart rate of 120/min is within the expected range for a 3-year-old and does not indicate immediate distress.
C. A child with type 1 diabetes and a blood sugar of 150 mg/dL is not the priority because this blood glucose level is slightly elevated but not critical.
D. A child with diarrhea and abdominal pain requires assessment, but dehydration or electrolyte imbalance develops over time. Airway issues take priority over gastrointestinal symptoms.
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