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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

Answer and Explanation

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.

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Correct Answer is ["B","D"]

Explanation

A. Blood pressure: The client’s BP is 128/84 mm Hg, which is within the normal range. Although the client has chronic hypertension, this BP reading does not indicate an immediate concern.

B. Fetal heart rate: The fetal heart rate (FHR) is 165/min, which is tachycardia (normal FHR range is 110–160/min). Fetal tachycardia can indicate infection, maternal fever, fetal distress, or hypoxia and requires immediate follow-up.

C. Fetal station: The station is 0, which means the presenting part is at the level of the ischial spines. This is normal for a laboring client at 4 cm dilation and does not require immediate intervention.

D. Characteristics of amniotic fluid: The fluid is green, indicating the presence of meconium-stained amniotic fluid, which suggests fetal distress or hypoxia. This requires immediate follow-up, as the baby is at risk for meconium aspiration syndrome.

E. Duration of contraction: The contraction lasted 40 seconds, which is within the normal range (30–90 seconds). This is not an immediate concern.

A. The guardian wants to accompany the child from the ED to the radiology department. B. The guardian states the child fell off the swing in the backyard. C. The child was brought to the ED 2 days after the injury occurred. D. The child cries loudly when their arm is moved or manipulated.

Correct Answer is C

Explanation

A. The guardian wants to accompany the child from the ED to the radiology department. This is a typical parental response and does not indicate maltreatment. Parents often want to stay with their child for reassurance.
B. The guardian states the child fell off the swing in the backyard. This is a plausible explanation for an injury in a preschooler, though the consistency of the story with the injury should still be assessed.
C. The child was brought to the ED 2 days after the injury occurred. A delay in seeking medical care for a significant injury is a potential warning sign of child maltreatment and warrants further investigation.
D. The child cries loudly when their arm is moved or manipulated. Pain with movement is expected with a fracture and does not indicate maltreatment.

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Naxlex Comprehensive Predictor Exams

A nurse in an antepartum unit is caring for a client. Exhibits Select the 2 findings that require immediate follow-up.

Correct Answer is ["B","D"]

Explanation

A nurse in an emergency department (ED) is assessing a preschooler who has a fractured arm. For which of the following should the nurse further investigate as a warning sign of child maltreatment?

Correct Answer is C

Explanation

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A nurse in an antepartum unit is caring for a client. Exhibits Which of the following actions should the nurse take? Select all that apply.

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