Try Naxlex NCLEX-RN (Free-Trial)

The nurse is observing a family member administer eye drops to the patient as part of medication teaching. Which action(s) indicate the family member is performing the skill correctly? (SELECT ALL THAT APPLY)

Puts the eye drops in a room with low lighting

Washes their hands before placing the eye drops

Uses the patient’s iris as a landmark for direct placement of the drop

Puts the drop from inner to outer canthus

Holds the upper eyelid open when placing the drop

Answer and Explanation

Correct Answer : B,D

b. Washes their hands before placing the eye drops

d. Puts the drop from inner to outer canthus

Explanation of Choices

Choice A Reason: Puts the Eye Drops in a Room with Low Lighting

Administering eye drops in a room with low lighting is not a recommended practice. Proper lighting is essential to ensure accurate placement of the drops and to avoid contamination or injury. Low lighting can make it difficult to see the eye and the dropper, increasing the risk of improper administration. Therefore, this action does not indicate correct performance of the skill.

Choice B Reason: Washes Their Hands Before Placing the Eye Drops

Washing hands before administering eye drops is a crucial step to prevent infection and contamination. Clean hands reduce the risk of transferring bacteria or other pathogens to the eye, which can cause infections or other complications. This action is a fundamental part of proper eye drop administration and indicates correct performance of the skill.

Choice C Reason: Uses the Patient’s Iris as a Landmark for Direct Placement of the Drop

Using the patient’s iris as a landmark for direct placement of the drop is incorrect. The proper technique involves pulling down the lower eyelid to create a small pocket (conjunctival sac) and placing the drop into this pocket. Directly aiming for the iris can cause discomfort and increase the risk of injury or contamination. Therefore, this action does not indicate correct performance of the skill.

Choice D Reason: Puts the Drop from Inner to Outer Canthus

Placing the drop from the inner to the outer canthus (corner of the eye) is a correct technique. This method helps ensure that the drop spreads evenly across the eye surface and reduces the risk of contamination. It also helps in preventing the dropper from touching the eye or eyelid, which can introduce bacteria. This action indicates correct performance of the skill.

Choice E Reason: Holds the Upper Eyelid Open When Placing the Drop

Holding the upper eyelid open when placing the drop is not the recommended technique. The proper method involves pulling down the lower eyelid to form a pocket and placing the drop into this pocket. Holding the upper eyelid open can cause discomfort and may not allow the drop to be placed accurately. Therefore, this action does not indicate correct performance of the skill.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

d. Speaks another language and is in need of an interpreter to translate.

The correct answer is…

c. Is accompanied by a family member who will not let the client answer questions.

Choice A Reason:

The statement that the client is from another state and says they are here on a long vacation could be a sign of human trafficking, but it is not definitive. People often travel for various reasons, and being from another state does not necessarily indicate trafficking. However, if combined with other suspicious behaviors, it could raise concerns. Traffickers often move victims to different locations to avoid detection, but this alone is not enough to suspect trafficking.

Choice B Reason:

Having a cell phone that is not working in the emergency department might be suspicious, but it is not a strong indicator of human trafficking. There could be many reasons for a non-functioning cell phone, such as technical issues or lack of service. While traffickers might control victims’ communication devices, this alone does not provide enough evidence to suspect trafficking.

Choice C Reason:

Being accompanied by a family member who will not let the client answer questions is a strong indicator of human trafficking. Traffickers often pose as family members or friends to maintain control over their victims and prevent them from speaking freely. This behavior is a red flag because it suggests that the accompanying person is trying to control the interaction and possibly hide something. Healthcare providers are trained to recognize this as a potential sign of trafficking.

Choice D Reason:

Speaking another language and needing an interpreter to translate is not a strong indicator of human trafficking. Many people who are not victims of trafficking may speak different languages and require translation services. While language barriers can complicate communication, they are not in themselves indicative of trafficking. However, if combined with other suspicious behaviors, it could contribute to the overall assessment.

Correct Answer is ["125"]

Explanation

Calculation Steps

Step 1: Convert 1 liter to milliliters (mL).

1 liter = 1000 mL

Result: 1000 mL

Step 2: Determine the total time in hours.

Total time = 8 hours

Result: 8 hours

Step 3: Calculate the infusion rate in milliliters per hour (mL/hr).

Infusion rate = Total volume (mL) ÷ Total time (hours)

Step 4: Perform the division.

1000 mL ÷ 8 hours = 125 mL/hr

Result: 125 mL/hr

Therefore, the nurse should set the infusion pump to 125 mL/hr.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is observing a family member administer eye drops to the patient as part of medication teaching. Which action(s) indicate the family member is performing the skill correctly? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a client who is malnourished and appears exhausted. What data would cause the nurse to suspect the client is a victim of human trafficking? The client:

Correct Answer is C

Explanation

One liter of normal saline is to infuse over 8 hours. At what rate will the nurse set the infusion pump?

Correct Answer is ["125"]

Explanation

The nurse assesses that medication teaching about tricyclic antidepressants was understood when the client states:

A client with a history of a suicide attempt has been discharged and is being followed in an outpatient clinic. What is/are the most appropriate nursing intervention(s)? (SELECT ALL THAT APPLY)

The highest priority nursing action relative to the initial phase of alcohol withdrawal would be to:

A client is to receive a continuous Heparin infusion at s00 units per hour. Pharmacy supplies Heparin in a concentration of 25,000 units per 250mL of NSS. Calculate the rate at which the nurse should set the infusion pump.

Edited TextA client with borderline personality disorder reported to the nurse in the clinic that they feel empty and anxious. The client wants to cut their arms. The nurse should first:

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. Which screening tool should the nurse use to further evaluate this possibility?

The intervention appropriate for a client who has been manipulating others and has a diagnosis of antisocial personality disorder is to:

The nurse is educating clients about recovery from alcohol abuse. Which statement by the client indicates that learning has occurred?