A nurse is preparing to administer timolol eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take?
Instruct the client to blink several times after instillation of the medication.
Ask the client to look straight ahead during instillation of the medication.
Apply pressure to the bridge of the nose after instillation of the medication.
Place each drop of the medication directly on to the client's cornea.
The Correct Answer is C
Choice A reason: This is an incorrect action, because instructing the client to blink several times after instillation of the medication can cause the medication to drain out of the eye and reduce its effectiveness.
Choice B reason: This is a correct action, but not the best one. Asking the client to look straight ahead during instillation of the medication can help the nurse to aim the drop accurately and avoid touching the eye with the dropper.
Choice C reason: This is the best action, because applying pressure to the bridge of the nose after instillation of the medication can prevent the medication from entering the systemic circulation and causing adverse effects, such as bradycardia, hypotension, or bronchospasm.
Choice D reason: This is an incorrect action, because placing each drop of the medication directly on to the client's cornea can cause irritation, injury, or infection to the eye. The medication should be placed in the lower conjunctival sac of the eye.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
The correct answer is A, C, D
Choice A reason: Allopurinol is a medication that helps reduce the production of uric acid, which is beneficial for patients with gout and urolithiasis to prevent the formation of uric acid stones.
Choice B reason: While regular exercise is generally beneficial for overall health, it does not have a direct impact on the prevention of uric acid stone formation. Therefore, it is not a specific recommendation for preventing uric acid stone.
Choice C reason: Foods high in purines can increase uric acid levels in the body, leading to the formation of uric acid stones. Limiting the intake of such foods is a key step in preventing uric acid stones.
Choice D reason: Adequate fluid intake is crucial as it helps to dilute the urine, which can prevent the formation of uric acid stones by reducing the concentration of uric acid in the urine.
Choice E reason: Contrary to the statement, lemonade may actually be beneficial in preventing uric acid stones because it contains citrate, which can help prevent stone formation. Citrate can bind to calcium and prevent stone formation, and it also makes the urine less acidic, which can help prevent the formation of uric acid stones.
Correct Answer is A
Explanation
Choice A reason: This is the correct information, because pursed-lip breathing can help improve gas exchange by creating positive pressure in the airways, preventing air trapping and alveolar collapse, and increasing the exhalation time.
Choice B reason: This is an incorrect information, because limiting fluid intake to 1,500 ml per day can cause dehydration and thickening of the respiratory secretions, which can impair gas exchange and increase the risk of infection.
Choice C reason: This is an incorrect information, because practicing chest breathing each day can worsen gas exchange by increasing the use of accessory muscles, decreasing the diaphragmatic excursion, and reducing the lung expansion.
Choice D reason: This is an incorrect information, because wearing home oxygen to maintain an SpO2 of at least 94% can be harmful for a client who has emphysema, as it can suppress the hypoxic drive and cause carbon dioxide retention, which can lead to respiratory acidosis and coma. The client who has emphysema should wear home oxygen to maintain an SpO2 of 88% to 92%, or as prescribed by the provider.
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