A nurse is providing teaching to a client who is to self-administer an ophthalmic solution. Which of the following statements by the client indicates an understanding of the teaching?

I will press the inner corner of my eye after I insert the drops.

I will raise my eyelid up while looking down to insert the drops.

I will keep my eyes closed for 5 minutes after inserting the drops.

I will insert the drops in the center of each eye.

Answer and Explanation

The Correct Answer is A

The correct answer is that the client should press the inner corner of their eye after inserting the drops. This technique is called punctal occlusion and it helps to prevent the eye drops from draining into the tear duct and being absorbed by the rest of the body. This can increase the eﬀectiveness of the eye drops and reduce potential side eﬀects.

Options b, c and d are not correct statements by the client that indicate an understanding of how to self- administer an ophthalmic solution. Raising the eyelid up while looking down to insert the drops, keeping eyes closed for 5 minutes after inserting the drops and inserting the drops in the center of each eye are not recommended techniques for self-administering an ophthalmic solution.

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Correct Answer is ["F"]

Explanation

f) Skin surrounding the stoma is reddened and appears irritated.

The information that requires intervention by the nurse is that the skin surrounding the stoma is reddened and appears irritated. This may indicate that the client is experiencing skin irritation or breakdown, which can lead to infection or other complications. The nurse should assess the skin and initiate appropriate interventions to prevent further skin damage.

Options a, b, c, d, e, and g do not necessarily require intervention by the nurse. A pink ileostomy stoma and moderate brown liquid stool drainage are normal findings. The client's refusal to look at the stoma or learn about stoma care may be concerning, but it is not an immediate priority for intervention. An intake of 2,200 mL over 24 hours and a urine output of 650 mL over 24 hours are within normal limits.

A. Stop the transfusion. B. Place the client in high-Fowler's position. C. Administer epinephrine to the client. D. Obtain a prescription for a diuretic. E. Administer oxygen to the client.

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

Explanation

The nurse should stop the transfusion, place the client in high-Fowler's position, obtain a prescription for a diuretic, and administer oxygen to the client. These actions can help manage the symptoms of transfusion- associated circulatory overload (TACO), which can occur when a client receives too much ﬂuid too quickly during a blood transfusion.

c. Administering epinephrine is not an appropriate action for managing TACO. Epinephrine is used to treat anaphylaxis, which is a diﬀerent type of transfusion reaction.

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A nurse is providing teaching to a client who is to self-administer an ophthalmic solution. Which of the following statements by the client indicates an understanding of the teaching?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["F"]

Explanation

A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

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

Explanation

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