A nurse is reinforcing teaching with a client with bacterial conjunctivitis of the right eye, and a prescription for an antibiotic ophthalmic ointment. Which of the following statements should the nurse make?

"Apply the ointment in a thin line into the conjunctival sac."

"Keep your eye open for 30 sec after instilling the ointment."

"Use a sterile glove and applicator to apply the antibiotic ointment."

"Always wipe from the outer to the inner canthus when wiping away secretions."

Answer and Explanation

The Correct Answer is A

A) "Apply the ointment in a thin line into the conjunctival sac":
This instruction is correct for applying ophthalmic ointments. Placing the ointment in a thin line along the conjunctival sac ensures proper distribution and contact with the affected area.

B) "Keep your eye open for 30 sec after instilling the ointment":
Keeping the eye open for a brief period after instillation helps the ointment spread across the eye surface. This statement indicates understanding of the proper technique for applying ophthalmic ointments and does not require further instruction.

C) "Use a sterile glove and applicator to apply the antibiotic ointment":
Using a sterile glove and applicator ensures that the application is done in a sterile manner, reducing the risk of introducing further infection. This statement indicates a need for further instruction, as ophthalmic ointments are typically applied using clean hands or disposable, sterile applicators rather than sterile gloves.

D) "Always wipe from the outer to the inner canthus when wiping away secretions":
Wiping from the outer to the inner canthus helps prevent contamination of the unaffected eye. This statement demonstrates understanding of proper eye care techniques and does not require further instruction.

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Correct Answer is D

Explanation

A) "Clients who have rheumatoid arthritis should not take warfarin":
Rheumatoid arthritis itself is not a contraindication for warfarin therapy. However, close monitoring is required due to potential interactions with medications used to treat rheumatoid arthritis and the increased risk of bleeding associated with both conditions.

B) "Clients who have diabetes mellitus type 1 should not take warfarin":
Type 1 diabetes mellitus is not a contraindication for warfarin therapy. However, diabetes increases the risk of complications such as peripheral vascular disease, which may necessitate careful monitoring of INR levels and adjustments to warfarin dosage.

C) "Clients who have hypertension should not take warfarin":
Hypertension alone is not a contraindication for warfarin therapy. However, hypertension is a risk factor for cardiovascular diseases that may require anticoagulation therapy. Close monitoring of blood pressure and potential interactions with antihypertensive medications is essential.

D) "Clients who are pregnant should not take warfarin":
Pregnancy is a contraindication for warfarin therapy due to its teratogenic effects, which can cause fetal harm or birth defects. Pregnant clients requiring anticoagulation therapy may be prescribed alternative medications that are safer during pregnancy, under the guidance of a healthcare provider.

A. "Heparin enhances the effects of the warfarin." B. "Both heparin and warfarin work together to dissolve the clots." C. "Heparin will be continued until the warfarin reaches a therapeutic level!" D. "I will ask the charge nurse to call your provider and get an explanation"

Correct Answer is C

Explanation

A) "Heparin enhances the effects of the warfarin.": This statement is incorrect. Heparin and warfarin work through different mechanisms. Heparin acts quickly by inhibiting clot formation through antithrombin, while warfarin acts slower by inhibiting vitamin K-dependent clotting factors. They do not directly enhance each other's effects.

B) "Both heparin and warfarin work together to dissolve the clots.": This is inaccurate. Neither heparin nor warfarin dissolve existing clots; they prevent new clots from forming and existing clots from growing. The body's natural processes will eventually dissolve the clot.

C) "Heparin will be continued until the warfarin reaches a therapeutic level!": This is correct. Heparin is used initially because it acts quickly. Warfarin takes several days to reach therapeutic levels. Overlapping the two ensures continuous anticoagulation until warfarin is effective.

D) "I will ask the charge nurse to call your provider and get an explanation.": While involving the provider for further explanation can be helpful, it does not directly answer the client’s question. Providing accurate information about the overlapping use of heparin and warfarin is more appropriate in this context.

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A nurse is reinforcing teaching with a client with bacterial conjunctivitis of the right eye, and a prescription for an antibiotic ophthalmic ointment. Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the education of a group of clients about the contraindications of warfarin therapy. Which of the following statements is appropriate to include in the instructions?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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A nurse is reinforcing teaching with a client with bacterial conjunctivitis of the right eye, and a prescription for an antibiotic ophthalmic ointment. Which of the following statements should the nurse make?