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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

Explanation

A. Stating that the client received morphine "around lunch" is too vague. The exact time, dose, and effect should be included for accurate pain management.
B. A lung biopsy is a significant procedure that requires close monitoring for complications such as pneumothorax or bleeding. The oncoming nurse must be aware to provide appropriate post-procedure care.
C. General information about vital signs being taken every 4 hours is routine and not critical for handoff unless there are abnormalities or changes.
D. The presence of the client’s partner is not essential clinical information unless it impacts care, such as decision-making or emotional support needs.

A. Administer a stimulant to the client. B. Administer a diuretic to the client. C. Measure the client's urine specific gravity. D. Insert an NG tube for the client.

Correct Answer is C

Explanation

A. Stimulants should not be administered to clients with acute alcohol toxicity, as they can increase agitation and cardiovascular stress.
B. Diuretics are not used for alcohol toxicity because they do not effectively eliminate alcohol and may contribute to dehydration.
C. Measuring urine specific gravity helps assess hydration status and kidney function, which can be affected by acute alcohol toxicity.
D. An NG tube is not routinely indicated unless the client is at risk for aspiration or requires gastric lavage due to severe intoxication.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing change-of-shift report about a client to an oncoming nurse. Which of the following information should the nurse include?

Correct Answer is B

Explanation

A nurse is caring for a client who is experiencing acute alcohol toxicity. Which of the following actions should the nurse include in the plan?

Correct Answer is C

Explanation

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