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 {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
Anticipated Interventions:
- Initiate an IV infusion of lactated Ringer's
- Place the client in a left lateral position
- Maintain continuous monitoring of the FHR
Contraindicated Intervention:
- Monitor blood pressure every hour
Rationale:
- Initiate an IV infusion of lactated Ringer’s: Hydration is important for labor progression and maternal hemodynamic stability, especially considering the client has a history of chronic hypertension and gestational diabetes.
- Place the client in a left lateral position: This improves uteroplacental perfusion, helping to optimize fetal oxygenation.
- Maintain continuous monitoring of the FHR: The presence of meconium-stained amniotic fluid and an elevated FHR (165/min) suggests potential fetal distress, warranting continuous fetal monitoring.
- Monitor blood pressure every hour (Contraindicated): The client has chronic hypertension and gestational diabetes, both of which increase the risk for complications like preeclampsia and fetal distress. More frequent BP monitoring (e.g., every 15-30 minutes) is necessary to detect any abnormalities early.
Correct Answer is B
Explanation
A. Protective environment. This is incorrect because a protective environment is used for immunocompromised clients, not for those with bacterial meningitis.
B. Droplet. This is correct because bacterial meningitis is transmitted through respiratory secretions. Droplet precautions, including wearing a mask when within 3 to 6 feet of the client, are necessary to prevent the spread of infection.
C. Contact. This is incorrect because bacterial meningitis is not primarily transmitted through direct contact with surfaces or bodily fluids, making contact precautions unnecessary.
D. Airborne. This is incorrect because bacterial meningitis does not spread through airborne particles that remain suspended in the air, so airborne precautions are not required.
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