A nurse is administering multiple types of ophthalmic drops to a client. Which of the following actions should the nurse take?

Hold the dropper 3 cm (1.2 in) away from the client's eye.

Massage the client's eyelids for 20 seconds after instillation.

Wait 5 min between the administration of each medication.

Ask the client to close their eyes tightly after instilling each medication.

Answer and Explanation

The Correct Answer is C

A.   The dropper should be held about 1 cm (0.4 in) away from the eye to avoid touching or injuring the eye or contaminating the dropper tip.
B.   Massaging the eyelids after instillation is not a standard practice and may cause discomfort or injury to the eye.
C.   Administering multiple ophthalmic medications requires a sufficient interval between doses to prevent interactions and ensure effectiveness.
D.   Asking the client to close their eyes tightly may squeeze out some of the medication or increase intraocular pressure.

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Free Nursing Study Resources

Correct Answer is D,E,C,B,A

Explanation

A. Deep palpation is the final step in an abdominal examination since it may elicit tenderness which may interfere with other aspects of examination.
B. This is the second last step just before deep palpation. It is used to detect any obvious masses or areas of tenderness.
C. Percussion is the third step in an abdominal examination where the nurse should percuss the client's abdomen systematically, tapping lightly on each area and noting the sound quality. It can be used to detect the presence of ascites which be stony dull on percussion.
D. Inspection is the first step where the nurse should inspect the contours of the client's abdomen using a penlight, looking for any abnormalities or distension.

E. Auscultation is the second step in an abdominal examination. The nurse should auscultate the client's abdomen using the diaphragm of the stethoscope, listening for bowel sounds in all four quadrants.

A. Notify the facility's risk management team. B. Assess the client for a change in condition. C. Place an incident report in the client's electronic medical record. D. Administer an antidote before notifying the provider.

Correct Answer is B

Explanation

A. While it may be necessary to notify risk management eventually, the immediate priority is to ensure the client's safety and well-being.
B. The nurse should promptly assess the client for signs and symptoms of an allergic reaction and initiate appropriate interventions as necessary.
C. Documentation of the medication error and allergic reaction should be completed after ensuring the client's immediate needs are addressed.
D. Administering an antidote may be appropriate in certain situations, but the nurse should first assess the client's condition and follow established protocols for managing allergic reactions.

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A nurse is administering multiple types of ophthalmic drops to a client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's abdomen. In what order should the nurse complete the steps of the assessment? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is D,E,C,B,A

Explanation

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Correct Answer is B

Explanation

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