The practical nurse (PN) is assisting a client to the bathroom after a right cataract extraction. The client has an eye shield over the right eye. How should the PN assist the client during ambulation?
Place the client in front of the nurse while both walk to the bathroom.
Stand in front of the client and lead the client forward to the bathroom.
Walk on the client's left side while assisting the client to the bathroom.
Support the client on the right side while walking to the bathroom.
The Correct Answer is C
A. Placing the client in front of the nurse can be disorienting and unsafe, especially since the client has limited vision with the eye shield. The PN should be in a position to provide guidance and support.
B. Standing in front of the client while leading them could be confusing for the client, as they might not see where they are going. The PN should be positioned where they can offer clear support and direction.
C. Walking on the client’s left side is the best approach as it ensures that the PN is on the side of the unaffected eye. This position allows the PN to guide and support the client while the shielded eye is protected from potential hazards.
D. Supporting the client on the right side could interfere with the eye shield and the healing process. The PN should assist from the left side to avoid disturbing the protected eye and to provide better guidance.
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Correct Answer is D
Explanation
A. Measles Mumps Rubella (MMR) vaccine is typically administered at 12-15 months of age, not at 2 months. It is part of the recommended immunization schedule but is not given during the 2-month visit.
B. Varicella vaccine is usually given at 12-15 months of age. It is essential for preventing chickenpox but is not included in the 2-month immunization schedule.
C. Hepatitis A vaccine is recommended starting at 12 months of age. It is not part of the immunizations administered at 2 months.
D. Hepatitis B vaccine is part of the routine immunization schedule for infants and is given at birth, 1-2 months, and 6-18 months. At the 2-month visit, it is appropriate to administer the second dose of the Hepatitis B vaccine if it was not given at 1 month.
Correct Answer is D
Explanation
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B. Ketorolac does not require peak and trough serum level monitoring. This practice is more relevant for medications with narrow therapeutic ranges or those requiring precise dosage adjustments, which is not the case for ketorolac.
C. Observing for involuntary movements of the lips and tongue is not a primary concern for ketorolac therapy. This is more relevant to medications like antipsychotics that can cause extrapyramidal symptoms.
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