A nurse is teaching a client who has glaucoma and is to start taking timolol. Which of the following information should the nurse include?

Notify the provider if you experience a stinging sensation following administration.

Watch for a decreased heart rate while using this medication.

You can expect to develop a harmless darkening of the iris.

This medication can cause the lashes of the affected eye to lengthen.

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Notifying the provider if you experience a stinging sensation following administration is not necessary. A mild stinging sensation is a common side effect of timolol eye drops and usually subsides quickly. However, if the stinging persists or is severe, it should be reported.

Choice B Reason:

Watching for a decreased heart rate while using this medication is important. Timolol is a beta-blocker, and one of its systemic side effects can be bradycardia (a slower than normal heart rate). Patients should be aware of this potential side effect and monitor their heart rate regularly.

Choice C Reason:

Developing a harmless darkening of the iris is not associated with timolol. This side effect is more commonly linked to prostaglandin analogs, another class of medications used to treat glaucoma.

Choice D Reason:

Timolol does not cause the lashes of the affected eye to lengthen. This side effect is also associated with prostaglandin analogs, not beta-blockers like timolol.

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Correct Answer is A

Explanation

Choice A Reason:

A distended, board-like abdomen is a critical finding that can indicate peritonitis, a severe complication of appendicitis. Peritonitis occurs when the appendix ruptures, leading to infection spreading throughout the abdominal cavity. This condition requires immediate medical intervention to prevent further complications and potential sepsis.

Choice B Reason:

A WBC count of 15,000/mm³ is elevated and suggests an infection, which is common in appendicitis. However, it is not as immediately critical as signs of peritonitis. Elevated WBC counts are expected in cases of appendicitis but do not necessarily indicate a life-threatening emergency.

Choice C Reason:

Rebound tenderness over McBurney’s point is a classic sign of appendicitis and indicates localized inflammation. While it is an important diagnostic sign, it does not require immediate reporting compared to signs of peritonitis.

Choice D Reason:

A temperature of 37.3°C (99.1°F) is only slightly elevated and does not indicate a severe infection or complication. Fever is a common symptom of appendicitis but is not as critical as a distended, board-like abdomen.

A. A client who has a chest tube and reports a pain level of 6 on a scale of 0 to 10. B. A client who received parenteral cephalosporin and reports urticaria and edema. C. A client who is being admitted with bilateral stage 3 pressure injuries on both heels. D. A client who has a systemic infection and an oral temperature of 39.1°C (102.4°F).

Correct Answer is B

Explanation

Choice A Reason

A client who has a chest tube and reports a pain level of 6 on a scale of 0 to 10. While pain management is important, this client is not in immediate life-threatening danger. Pain can be addressed after ensuring there are no urgent allergic reactions or other critical conditions.

Choice B Reason

A client who received parenteral cephalosporin and reports urticaria and edema. This is the correct choice. Urticaria (hives) and edema (swelling) can indicate an allergic reaction, which can progress to anaphylaxis, a life-threatening condition. Immediate assessment and intervention are required to prevent severe complications.

Choice C Reason

A client who is being admitted with bilateral stage 3 pressure injuries on both heels. While stage 3 pressure injuries are serious and require prompt attention, they do not pose an immediate life-threatening risk compared to a potential anaphylactic reaction.

Choice D Reason

A client who has a systemic infection and an oral temperature of 39.1°C (102.4°F). Although a systemic infection with a high fever is concerning and needs timely intervention, it is not as immediately life-threatening as a potential anaphylactic reaction.

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A nurse is teaching a client who has glaucoma and is to start taking timolol. Which of the following information should the nurse include?

Nursing Test Bank

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