A client receives a prescription for ophthalmic ketorolac. Prior to administering the medication, the nurse should review the medical record for which condition?
Corneal abrasion.
Chemical burn.
Radiation exposure.
Foreign body.
The Correct Answer is A
Choice A rationale
Corneal abrasion is a contraindication for the use of ophthalmic ketorolac. Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that can delay healing and increase the risk of further damage to the cornea.
Choice B rationale
Chemical burns are not a primary contraindication for ophthalmic ketorolac. However, the treatment of chemical burns typically involves other specific interventions, and the use of ketorolac should be carefully considered.
Choice C rationale
Radiation exposure is not a direct contraindication for the use of ophthalmic ketorolac. The medication is used to reduce inflammation and pain, which may be beneficial in managing symptoms related to radiation exposure.
Choice D rationale
A foreign body in the eye is not a primary contraindication for ophthalmic ketorolac. However, the foreign body should be removed, and the eye should be thoroughly examined before administering any medication.
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Correct Answer is C
Explanation
Choice A rationale
Offering mouthwash for thorough cleansing after brushing teeth can be too harsh for clients with painful mouth ulcers caused by Candida albicans. It may cause further irritation and discomfort.
Choice B rationale
While assistive personnel can help with personal care, oral care should not be left solely to the nurse. Providing appropriate tools and guidance for the client to perform oral care is essential.
Choice C rationale
Providing a soft-bristled toothbrush is appropriate for clients with oral Candida albicans. It helps in gentle cleaning without causing additional pain or damage to the mucosa.
Choice D rationale
Wearing sterile gloves is not necessary for routine oral care. Clean gloves are sufficient unless there is a specific need for sterility, such as in surgical procedures.
Correct Answer is C
Explanation
Choice A rationale
Attaching humidification to oxygen delivery can help with comfort but is not the immediate priority in assessing the client’s respiratory status.
Choice B rationale
Coaching through using huff coughing is a useful technique for clearing secretions but should follow the assessment of the client’s oxygenation status.
Choice C rationale
Obtaining a pulse oximetry reading is the next immediate action after positioning the client upright. It provides essential information about the client’s oxygen saturation and helps guide further interventions.
Choice D rationale
Providing a nebulizer breathing treatment can help relieve symptoms but should be based on the assessment of the client’s oxygenation status.