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 C
Explanation
A. Feeling pulsations in the neck is not an expected sensation during electroconvulsive therapy (ECT). The client is under general anesthesia and does not feel the procedure.
B. The client typically wakes up within 5 to 10 minutes after ECT, though they may remain drowsy for a while. 30 minutes is too long for initial awakening.
C. Post-procedure confusion and memory loss are common and temporary side effects of ECT, lasting a few hours to days in some cases.
D. Voice changes are not associated with ECT. The procedure does not affect the vocal cords or speech.
Correct Answer is C
Explanation
A. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm. This is incorrect because the arteriovenous shunt is in the lower forearm, not the upper arm where blood pressure is measured. The right arm can still be used.
B. A client who had a right hemisphere stroke. This is incorrect because a stroke does not necessarily contraindicate blood pressure measurement on the affected side unless there are complications such as edema or weakness.
C. A client who has a right peripherally inserted central catheter. This is correct because taking a blood pressure on the same side as a peripherally inserted central catheter (PICC) can cause pressure that may damage the catheter or affect its function. The left arm should be used instead.
D. A client who had blood drawn from the right antecubital area 1 hr ago. This is incorrect because drawing blood from an arm does not contraindicate blood pressure measurement in that arm after a short period.
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