A nurse is instructing the caregiver of a toddler who has bacterial conjunctivitis and a new prescription for an ophthalmic ointment. Which of the following instructions should the nurse provide?

"Ask the child to look down before applying the ointment.”.

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

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

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

Answer and Explanation

The Correct Answer is B

Choice A rationale

Directing the toddler to look downward actually positions the cornea in the path of the medication application, increasing the risk of irritation or injury. For proper administration of ophthalmic ointment, the patient should be instructed to look upward. This action exposes the lower conjunctival sac and moves the sensitive cornea away from the tip of the tube, ensuring the medication is deposited safely and effectively without causing corneal trauma.

Choice B rationale

Applying the ointment in a thin line along the lower conjunctival sac is the standard technique for ophthalmic medications. This anatomical space allows the medication to be distributed evenly across the ocular surface as the patient blinks. A thin line is sufficient to achieve therapeutic levels of the antibiotic while minimizing blurred vision. This method ensures the medication contacts the inflamed conjunctiva directly to treat the bacterial infection efficiently while avoiding excessive wastage.

Choice C rationale

Cleaning secretions from the outer to the inner canthus is incorrect because it risks pushing contaminated material and pathogens into the lacrimal duct and the opposite eye. The correct technique is to wipe from the inner canthus toward the outer canthus. This direction follows the natural flow of tears and moves bacteria away from the nasolacrimal system, thereby preventing the spread of infection and maintaining better ocular hygiene during the treatment.

Choice D rationale

Using a sterile glove and applicator is unnecessary for the application of ophthalmic ointment and may be cumbersome when treating a toddler. The nurse should instruct the caregiver to wash their hands thoroughly before and after the procedure. The tip of the ointment tube must remain sterile and should not touch the eye or any other surface. Hand hygiene and careful technique are sufficient to prevent cross-contamination without needing specialized sterile equipment.

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Correct Answer is A

Explanation

Choice A rationale

In the PQRST pain assessment mnemonic, the letter Q stands for Quality. This component focuses on the nature or character of the pain. By asking the client to describe what the pain feels like, the nurse is gathering descriptors such as sharp, dull, stabbing, burning, or crushing. This qualitative data helps healthcare providers differentiate between types of pain, such as visceral, somatic, or neuropathic, which is essential for determining the underlying pathological cause.

Choice B rationale

Precipitating cause, represented by the letter P in the mnemonic, refers to what triggers the pain or what the client was doing when it started. It also includes factors that provoke or palliate the sensation. Asking the client what the pain feels like does not address the onset or the activities that aggravate the condition. Instead, it focuses purely on the sensory description rather than the external or internal events that lead to the pain's occurrence.

Choice C rationale

Severity is represented by the letter S and involves quantifying the intensity of the pain, usually on a scale of 0 to 10. While describing the sensation is important, it does not provide a numerical or comparative measurement of how much it hurts. Severity assessment helps in evaluating the effectiveness of interventions and the urgency of the situation, whereas asking for a description of the feeling specifically targets the qualitative aspect of the client's experience.

Choice D rationale

Region or Radiation, represented by the letter R, identifies the specific anatomical location of the pain and whether it travels to other parts of the body. Asking a client to describe the feeling of the pain provides information about the type of sensation but does not clarify where the pain is located or its path of movement. To assess the region, the nurse would ask the client to point to the area where they feel discomfort.

A. Rhonchi. B. Crackles. C. Wheezes. D. Stridor.

Correct Answer is C

Explanation

Choice A rationale

Rhonchi are low-pitched, continuous snoring or rattling sounds caused by secretions or obstructions in the larger airways, such as the bronchi. They are often associated with conditions like chronic bronchitis or pneumonia and may clear with coughing. The description of a high-pitched, squeaking sound does not align with the characteristics of rhonchi, which are deeper and suggest the presence of thick mucus in the larger passages rather than narrowed smaller airways.

Choice B rationale

Crackles, also known as rales, are discontinuous, popping or bubbling sounds heard primarily during inspiration. They are caused by the sudden snapping open of small airways or alveoli that contain fluid. This occurs in conditions like heart failure or pulmonary edema. The sounds described in the question are continuous and high-pitched during exhalation, which is the opposite of the brief, non-continuous nature of crackles caused by fluid movement in distal air sacs.

Choice C rationale

Wheezes are high-pitched, continuous musical or squeaking sounds produced by air flowing through narrowed or constricted small airways. In asthma, bronchospasm and inflammation narrow the bronchioles, typically causing these sounds during expiration. The description of high-pitched squeaking during exhalation is the classic clinical presentation of wheezing. This indicates a significant reduction in the diameter of the airway lumen, requiring prompt assessment of the client’s respiratory effort and oxygen saturation levels.

Choice D rationale

Stridor is a harsh, high-pitched, vibrating sound caused by an obstruction in the upper airway, such as the larynx or trachea. It is usually loudest during inspiration and can often be heard without a stethoscope. Stridor is a medical emergency indicating a compromised upper airway. While high-pitched, it is localized to the throat area rather than the lower lung fields and sounds more like gasping or crowing than the squeaking associated with asthmatic wheezing.

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A nurse is instructing the caregiver of a toddler who has bacterial conjunctivitis and a new prescription for an ophthalmic ointment. Which of the following instructions should the nurse provide?

Nursing Test Bank

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