A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Apply pressure to the lacrimal punctum.
Place the child in a sitting position.
Instill the drops of medication.
Pull the lower eyelid downward.
The Correct Answer is B, D, C, A
Rationale:
A. Apply pressure to the lacrimal punctum: This step is performed last to prevent systemic absorption of the medication by blocking the nasolacrimal duct. Holding gentle pressure for about 1 minute helps maximize the local effect of the drops.
B. Place the child in a sitting position: Positioning the child upright or with the head slightly tilted back promotes comfort, stability, and proper visualization of the conjunctival sac for accurate drop placement.
C. Instill the drops of medication: Instillation should occur after exposing the conjunctival sac to ensure the medication reaches the target area. The dropper should not touch the eye to prevent contamination.
D. Pull the lower eyelid downward: This creates a conjunctival pocket that holds the medication and allows it to spread evenly over the eye surface without spilling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
A. ABG results: pH 7.32 (acidosis), HCO₃⁻ 18 mEq/L (low), PaO₂ 68 mm Hg, SaO₂ 90%. Indicates metabolic acidosis with hypoxemia. This is a significant abnormality needing prompt attention.
B. Amylase results: Elevated amylase is a hallmark of acute pancreatitis and confirms the suspected diagnosis.
C. Temperature: Fever with pancreatitis can signal systemic inflammatory response or infection, requires provider notification.
D. Hematocrit level: 42%, within the normal range (female 38–47%, male 42–52%).
E. Pain report: Severe abdominal pain 8/10, persistent >24 hours. Pancreatitis pain requires provider management (often opioids, supportive care).
F. Glucose level: 108 mg/dL is within normal limits (70–110). It is not concerning at this time.
Correct Answer is A
Explanation
Rationale:
A. Serum potassium: Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. Monitoring serum potassium is essential to detect elevated levels early and prevent cardiac complications.
B. Platelet count: Spironolactone does not significantly affect platelet production or function, so routine monitoring of platelets is not indicated for this medication.
C. Urine ketones: Ketone monitoring is relevant for clients with uncontrolled diabetes or ketosis, but it is not related to spironolactone therapy.
D. Total bilirubin: Bilirubin levels are used to assess liver function, which is not directly affected by spironolactone in most clients, so routine monitoring is not necessary unless the client has underlying hepatic disease.
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