The nurse begins a shift on a busy medical-surgical unit and will be caring for multiple clients. Which client does the nurse assess first?
A client who has a question about her daily medications
A client who needs discharge teaching about an antibiotic
A client who just received nitroglycerin for chest pain
A client who would like some acetaminophen (Tylenol) for a mild headache
The Correct Answer is C
A) A client who has a question about her daily medications: While it's important to address questions regarding medications, this client does not present an immediate clinical concern that requires urgent attention.
B) A client who needs discharge teaching about an antibiotic: Although discharge teaching is important, it is not an immediate priority compared to the potential instability of a client with chest pain.
C) A client who just received nitroglycerin for chest pain: This is the correct choice. A client who has received nitroglycerin needs to be closely monitored for its effects, including blood pressure and relief of chest pain. This situation is potentially critical, making it the highest priority for assessment.
D) A client who would like some acetaminophen (Tylenol) for a mild headache: While this request should be addressed, it is not as urgent as the need to assess the client who has recently received nitroglycerin. Managing a mild headache is less critical compared to monitoring a client with chest pain.
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Correct Answer is D
Explanation
A) While administering the eye drops, a drop lands on the client's outer lid, so the client administers another drop: This action requires further teaching. If a drop lands outside the eye, the client should not administer another drop without first cleaning the area. It’s important to avoid excessive dosing and to ensure the medication is delivered properly.
B) The client cleans the eye from the inner to the outer canthus: This is the correct technique. Cleaning the eye from the inner canthus to the outer canthus helps prevent the spread of debris and ensures a clean area for administering drops.
C) The client looks upward toward the ceiling and administers the eye drops in the conjunctival sac: This action is appropriate. Looking upward helps expose the conjunctival sac, making it easier to administer the drops effectively.
D) The client touches the conjunctival sac with the eyedropper to make sure she is in the correct location: This action requires further teaching. Touching the conjunctival sac with the eyedropper can introduce bacteria and lead to contamination or injury. The client should be advised to keep the dropper tip away from the eye to maintain sterility and safety.
Correct Answer is ["C","D","E"]
Explanation
A) Fill only the center of the conjunctival sac: This option is incorrect. When applying ophthalmic ointment, the ointment should be placed along the entire length of the conjunctival sac, not just the center, to ensure proper distribution and effectiveness.
B) Remove excess ointment from the lid with a cotton ball: This action is not recommended. Instead of using a cotton ball, which may introduce fibers or contaminants, excess ointment should be gently wiped away with a clean tissue or cloth if necessary. However, it is generally best to avoid excess application in the first place.
C) Remove gloves and perform hand hygiene: This option is correct. After applying the ointment, the nurse should remove gloves and perform hand hygiene to prevent any potential contamination and maintain proper infection control practices.
D) Ask the client to roll the eye around and from side to side: This is a correct action. Encouraging the client to roll their eyes helps distribute the ointment evenly across the surface of the eye, enhancing its effectiveness.
E) Ask the client to close the eyelids tightly to distribute ointment: This option is also correct. Closing the eyelids helps spread the ointment over the conjunctival surface, ensuring better coverage and absorption of the medication.