The practical nurse (PN) is reviewing instructions for the use of pilocarpine eye drops with a client who has glaucoma. The client states, "I should use these drops to anesthetize my eye if I experience eye pain.”. Which action should the PN implement?

Ask the client to describe the intensity of the eye pain using the numerical pain scale.

Remind the client that the action of the eye drops is to decrease internal eye pressure.

Document in the chart that the client understands the action and use of the eye drops.

Clarify with the client that eye pain in glaucoma is uncommon, so drops are rarely needed.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Asking the client to describe the intensity of the eye pain using the numerical pain scale is not the most relevant action in this situation. The client's statement indicates a misconception about the purpose of pilocarpine eye drops, so addressing this misunderstanding should be the focus.

Choice B rationale:

Reminding the client that the action of the eye drops is to decrease internal eye pressure is the appropriate action. Pilocarpine eye drops are used to treat glaucoma by reducing intraocular pressure, not to anesthetize the eye.

Choice C rationale:

Documenting in the chart that the client understands the action and use of the eye drops might be necessary but should not be the first action taken. The priority is to correct the client's misunderstanding about the eye drops.

Choice D rationale:

Clarifying with the client that eye pain in glaucoma is uncommon, so drops are rarely needed, is not accurate. While eye pain might not be a common symptom of glaucoma, pilocarpine eye drops are specifically used to manage intraocular pressure and are not intended to address eye pain.

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Correct Answer is C

Explanation

The correct answer is C. Oriented to person only.

Choice A rationale:

A blood pressure of 144/84 mmHg is slightly elevated but not critically high. While it is important to monitor, it does not immediately impact the instructions for morning care.

Choice B rationale:

An oxygen saturation measurement of 95 to 96% is within the normal range and indicates adequate oxygenation. This is important to monitor but does not require specific changes to morning care instructions.

Choice C rationale:

Being oriented to person only indicates a significant alteration in the client’s cognitive status, which is crucial for the UAP to be aware of. This affects the client’s ability to understand and follow instructions, and may require additional supervision and safety measures during care.

Choice D rationale:

A urinary output of 50 mL/hour is within the normal range (typically 30-50 mL/hour is considered adequate). While it is important to monitor, it does not necessitate immediate changes to morning care instructions.

: 1

A. It's OK if you don't want to look or talk about the mastectomy. I will be available when you're ready. B. You will feel better when you see that the incision is not as bad as you may think. C. Would you like me to call another nurse to be here while I show you the wound?. D. Part of recovery is accepting your new body image, and you will need to look at your incision.

Correct Answer is A

Explanation

The correct answer is choice A: "It's OK if you don't want to look or talk about the mastectomy. I will be available when you're ready.”.

Choice A rationale:

This response shows empathy and understanding, acknowledging the client's feelings and respecting her decision not to look at or discuss the incision. It allows the client to take control of her own emotions and healing process, while also reassuring her that the nurse will be available whenever she feels ready to talk or see the incision.

Choice B rationale:

Telling the client that she will feel better when she sees the incision minimizes her feelings and may be seen as dismissive. It does not address her emotions or concerns and can be counterproductive to building trust and rapport.

Choice C rationale:

Suggesting to call another nurse to be present while showing the wound might make the client feel uncomfortable or pressured. It is essential to establish a therapeutic nurse-client relationship, and forcing the issue could increase the client's distress.

Choice D rationale:

Telling the client that part of recovery is accepting her new body image and needing to look at her incision is insensitive and inappropriate. It is not the nurse's role to dictate how the client should feel about her body or her healing process. Such a response could potentially harm the nurse-client relationship and hinder the client's emotional healing.

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The practical nurse (PN) is reviewing instructions for the use of pilocarpine eye drops with a client who has glaucoma. The client states, "I should use these drops to anesthetize my eye if I experience eye pain.”. Which action should the PN implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client information is most important for the practical nurse (PN) to consider when providing instructions to the unlicensed assistive personnel (UAP) about providing morning care to a postoperative client?

Correct Answer is C

Explanation

At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

Correct Answer is A

Explanation

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