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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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Correct Answer is D

Explanation

A. Strain the client's urine. This is incorrect because straining urine is necessary for clients with radioactive seeds placed in the bladder, but not for prostate cancer brachytherapy, where the seeds typically remain in place.
B. Limit each of the client's visitors to 2 hr per day. This is incorrect because visitors should be limited to short durations, but the exact time is typically restricted to 30 minutes per visit rather than a total of 2 hours per day.
C. Attach a dosimeter to the client's gown. This is incorrect because a dosimeter should be worn by healthcare staff, not attached to the client. It helps monitor radiation exposure for staff members.
D. Instruct visitors to stay 1 m (3.3 feet) away from the client. This is correct because maintaining a safe distance from the client helps minimize radiation exposure for visitors. Visitors should also limit their time near the client and avoid close contact.

A. Administer oxygen at 10L/min via nonrebreather face mask. B. Request a prescription for hydralazine. C. Initiate a bolus of IV fluid. D. Assist the client to the left lateral position. E. Request a prescription for oxytocin. F. Notify the provider of the client's condition. G. Prepare to administer an amnioinfusion.

Correct Answer is ["A","C","D","F","G"]

Explanation

A. Administer oxygen at 10 L/min via nonrebreather face mask. The fetal heart rate (FHR) is 168/min with minimal variability, which indicates potential fetal distress or hypoxia. Providing oxygen can improve fetal oxygenation.

B. Request a prescription for hydralazine. Hydralazine is used for severe hypertension in pregnancy (BP ≥160/110 mm Hg). The client’s BP is 132/84 mm Hg, which does not indicate a need for antihypertensive medication at this time.

C. Initiate a bolus of IV fluid. IV fluid bolus can improve placental perfusion, increase maternal blood pressure (if hypotension is a concern), and correct fetal heart rate abnormalities. This is especially important with minimal variability.

D. Assist the client to the left lateral position. Repositioning to the left lateral position improves uteroplacental blood flow and may help correct FHR abnormalities.

E. Request a prescription for oxytocin. Oxytocin is used to augment labor. However, the priority here is managing fetal distress, not increasing contractions. Oxytocin may worsen fetal distress, so it is not appropriate at this time.

F. Notify the provider of the client's condition. The combination of tachycardia (FHR 168/min), minimal variability, and meconium-stained fluid indicates possible fetal distress. The provider must be notified immediately to determine further interventions.

G. Prepare to administer an amnioinfusion. Meconium-stained fluid increases the risk of meconium aspiration syndrome. An amnioinfusion (infusion of sterile fluid into the amniotic sac via an intrauterine catheter) can help dilute thick meconium and improve fetal well-being.

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is undergoing brachytherapy with a low-dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client's plan of care?

Correct Answer is D

Explanation

A nurse in an antepartum unit is caring for a client. Exhibits Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["A","C","D","F","G"]

Explanation

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