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A nurse is preparing to administer timolol eye drops to a client who has glaucoma. In which order should the nurse perform the following steps? (place the steps , placing them in the order of performance.)

Verify the clarity and color of the eye drops.

Tilt the client's head backward toward the ceiling.

Pull the client's lower lid down with the nondominant hand.

Administer the prescribed number of drops.

Apply gentle pressure to the client's punctum.

Administer the prescribed number of drops

Apply gentle pressure to the client's punctum

Tilt the client's head backward toward the ceiling

Pull the client's lower lid down with the nondominant hand

Verify the clarity and color of the eye drops

Answer and Explanation

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

Verify the clarity and color of the eye drops. Ensuring the medication is not expired or contaminated is the first step in safe administration.
Tilt the client's head backward toward the ceiling. This position helps prevent the drops from draining out of the eye.
Pull the client's lower lid down with the nondominant hand. This creates a small pocket for the eye drops to be instilled properly.
Administer the prescribed number of drops. The medication should be placed in the conjunctival sac, not directly on the cornea.
Apply gentle pressure to the client's punctum. This prevents systemic absorption by blocking the nasolacrimal duct and reduces systemic side effects.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Yogurt and granola is not appropriate because granola is hard and can be difficult to swallow, increasing the risk of aspiration.
B. Wheat toast with butter is not appropriate because toast is dry and can be difficult to chew and swallow, posing a choking hazard.
C. Pancakes with syrup are soft and easy to chew, making them a suitable choice for a mechanically altered diet. The syrup adds moisture, further aiding swallowing.
D. Banana and nut muffin is not appropriate because muffins can be dry and crumbly, and nuts are a choking hazard for clients with dysphagia.

A. Insert an NG tube for a client who requires enteral feedings. B. Record a client's intake after each meal. C. Obtain a client's vital signs every 4 hr. D. Instruct a client on the use of an incentive spirometer. E. Transfer a client to physical therapy.

Correct Answer is ["B","C","E"]

Explanation

A. Insert an NG tube for a client who requires enteral feedings. This is incorrect because inserting an NG tube requires assessment and skill beyond the scope of practice of assistive personnel. This task should be performed by a nurse.
B. Record a client's intake after each meal. This is correct because recording intake is a non-clinical task within the scope of an assistive personnel’s role.
C. Obtain a client's vital signs every 4 hr. This is correct because measuring and documenting vital signs is a standard duty that assistive personnel can perform.
D. Instruct a client on the use of an incentive spirometer. This is incorrect because client education is a nursing responsibility and cannot be delegated to assistive personnel.
E. Transfer a client to physical therapy. This is correct because assistive personnel can safely assist with client transfers as long as no clinical judgment is required.

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Naxlex Comprehensive Predictor Exams

A nurse is ordering a breakfast meal tray for a client who has dysphagia and a prescription for a mechanically altered diet. Which of the following foods should the nurse select?

Correct Answer is C

Explanation

A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse in an antepartum clinic is caring for four clients. Which of the following clients should the nurse assess first?

A nurse in a provider's office is talking with an older adult client who tells the nurse that they fear they are "aging badly" and feel "so useless." Which of the following assessment questions is the nurse's priority?

A nurse is implementing crisis intervention for a client following an incident of partner violence. Which of the following is the priority action for the nurse to take?

A nurse is assessing a client who has a sliding hiatal hernia. Which of the following findings should the nurse expect?

A nurse is observing an assistive personnel (AP) measure blood pressures from the right arms of a group of clients. The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients?

A nurse observes two assistive personnel (AP) discussing a client's information in the facility cafeteria. Which of the following actions should the nurse take?

A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of "tightness" in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?