A client receives a prescription for ophthalmic ketorolac.
Prior to administering the medication, the nurse should review the medical record for which condition?

Radiation exposure

Corneal abrasion

Chemical burn

Foreign body

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Radiation exposure to the eye is a serious condition that requires immediate medical attention. However, it is not a contraindication for ophthalmic ketorolac. In fact, ketorolac may be used to treat pain and inflammation associated with radiation exposure to the eye.

Ophthalmic ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that works by inhibiting the production of prostaglandins, which are substances that cause inflammation and pain.

Radiation exposure can damage the cells of the eye, leading to inflammation and pain. Ketorolac can help to reduce these symptoms.

However, it is important to note that ketorolac does not address the underlying cause of radiation exposure, and further treatment may be necessary.

Choice B rationale:

Corneal abrasion is a scratch on the surface of the cornea, the clear outer layer of the eye. It is a common eye injury that can be caused by a variety of factors, such as getting poked in the eye, rubbing the eye too hard, or wearing contact lenses for too long.

Ophthalmic ketorolac is contraindicated in patients with corneal abrasions because it can delay healing and increase the risk of infection.

This is because ketorolac inhibits the production of prostaglandins, which are involved in the healing process. Prostaglandins also play a role in fighting infection.

Therefore, using ketorolac in a patient with a corneal abrasion could potentially lead to a more serious infection.

Choice C rationale:

Chemical burn to the eye is a serious injury that requires immediate medical attention. Ophthalmic ketorolac is not typically used to treat chemical burns to the eye.

This is because ketorolac is not effective in reducing inflammation caused by chemical burns. In addition, ketorolac can potentially worsen the injury by delaying healing.

Choice D rationale:

Foreign body in the eye is a common eye injury that can be caused by a variety of objects, such as dust, sand, or metal shavings. Ophthalmic ketorolac is not typically used to treat foreign bodies in the eye.

This is because ketorolac will not help to remove the foreign body from the eye. In addition, ketorolac can potentially worsen the injury by delaying healing.

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Correct Answer is A

Explanation

Rationale for Choice A:

Pursed-lip breathing:

Creates back pressure in the airways, which helps to keep them open longer during exhalation.

Slows down the breathing rate, allowing for more complete exhalation and better emptying of the lungs. Prevents air trapping, which can worsen shortness of breath.

Promotes relaxation and reduces anxiety, which can also help to improve breathing.

Rationale for Choice B:

Side-lying position with knees bent:

May not be the most effective position for improving gas exchange in a client with emphysema. Could potentially restrict chest expansion and make breathing more difficult.

May not be comfortable for all clients.

Rationale for Choice C:

Increasing breathing rate:

Can lead to hyperventilation, which can worsen shortness of breath and anxiety. Can also cause fatigue and muscle exhaustion.

Rationale for Choice D:

Raising hands above the head:

Does not significantly expand the diaphragm or improve gas exchange. May actually make breathing more difficult for some clients.

A. Hypothermia. B. Tachypnea. C. Hypotension. D. Hypertension.

Correct Answer is B

Explanation

Choice A rationale:

Hypothermia is a condition in which the body's core temperature falls below 95°F (35°C). It is not directly indicated by the client's vital signs as presented in the question.

Other factors that would more strongly suggest hypothermia include exposure to cold environments, immersion in cold water, or impaired thermoregulation due to conditions like hypothyroidism or alcohol intoxication.

Choice C rationale:

Hypotension is a condition in which blood pressure is abnormally low. It is also not directly indicated by the client's vital signs as presented in the question.

Hypertension, on the other hand, is a condition in which blood pressure is abnormally high.

The client's history of hypertension, and the fact that he takes enalapril (an antihypertensive medication), suggests that he may be more likely to experience hypertension than hypotension.

Choice D rationale:

Hypertension, as mentioned above, is a condition in which blood pressure is abnormally high.

While it's possible that the client is experiencing hypertension, the question specifically asks about the condition indicated by the client's vital signs.

Tachypnea, or rapid breathing, is a more direct indication of the client's respiratory distress, which is a common symptom of pneumonia.

Choice B rationale:

Tachypnea is the most likely condition indicated by the client's vital signs.

Tachypnea is often a sign of respiratory distress, which can be caused by a variety of conditions, including pneumonia. When a person has pneumonia, their lungs become inflamed and filled with fluid, making it difficult to breathe.

This can lead to rapid, shallow breathing, which is called tachypnea.

Other signs of respiratory distress that may be present in a client with pneumonia include: Coughing

Wheezing Chest pain

Feeling short of breath

Use of accessory muscles to breathe (e.g., muscles in the neck and chest) Nasal flaring

Cyanosis (a bluish tint to the skin)

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A client receives a prescription for ophthalmic ketorolac.Prior to administering the medication, the nurse should review the medical record for which condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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A client receives a prescription for ophthalmic ketorolac.
Prior to administering the medication, the nurse should review the medical record for which condition?