Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a 3-year-old child who has acute bacterial conjunctivitis of the right eye and has been prescribed bacitracin ophthalmic ointment.
Which of the following actions should the nurse take?
A. Gently massage the eyelid to facilitate absorption of the medication.
Is not recommended. It can potentially cause discomfort or further irritation to the affected eye, especially in a young child. The ointment will naturally spread across the eye as the child blinks.
B. Wipe any excess medication from the inner canthus outward.
Bacitracin ophthalmic ointment is an antibiotic medication commonly used to treat bacterial eye infections such as conjunctivitis. Wiping any excess medication from the inner canthus outward, is important to prevent the accumulation of excessive ointment, which can cause discomfort and affect vision. Using a clean, sterile cotton ball or tissue, the nurse should gently wipe any excess ointment from the inner corner of the eye (inner canthus) and then move outward to remove the excess ointment.
C. Place an occlusive dressing on the affected eye to prevent the spread of infection.
Is not necessary for the treatment of bacterial conjunctivitis. It may impede proper air circulation and potentially worsen the infection. It is important to promote hygiene and prevent the spread of infection by encouraging proper handwashing and avoiding touching or rubbing the affected eye.
D. Instruct guardian to apply erythromycin ophthalmic ointment every morning for 14 days.
Is not appropriate in this case. Erythromycin is an alternative antibiotic commonly used for conjunctivitis, but since the child has been prescribed bacitracin ophthalmic ointment, the appropriate course of treatment would be to follow the prescribed medication as directed by the healthcare provider.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Comprehensive Predictor 2023 - Proctored Exam 1. Take the full exam now
Full Explanation
Explanation
B. Wipe any excess medication from the inner canthus outward
Bacitracin ophthalmic ointment is an antibiotic medication commonly used to treat bacterial eye infections such as conjunctivitis.
Wiping any excess medication from the inner canthus outward, is important to prevent the accumulation of excessive ointment, which can cause discomfort and affect vision. Using a clean, sterile cotton ball or tissue, the nurse should gently wipe any excess ointment from the inner corner of the eye (inner canthus) and then move outward to remove the excess ointment.
Gently massaging the eyelid to facilitate absorption of the medication in (option A) is not recommended. It can potentially cause discomfort or further irritation to the affected eye, especially in a young child. The ointment will naturally spread across the eye as the child blinks.
Placing an occlusive dressing on the affected eye in (option C) is not necessary for the treatment of bacterial conjunctivitis. It may impede proper air circulation and potentially worsen the infection. It is important to promote hygiene and prevent the spread of infection by encouraging proper handwashing and avoiding touching or rubbing the affected eye.
Instructing the guardian to apply erythromycin ophthalmic ointment every morning for 14 days in (option D) is not appropriate in this case. Erythromycin is an alternative antibiotic commonly used for conjunctivitis, but since the child has been prescribed bacitracin ophthalmic ointment, the appropriate course of treatment would be to follow the prescribed medication as directed by the healthcare provider.
Similar Questions
A nurse is contributing to the plan of care for a client who is experiencing a herpes simplex outbreak. Which of the following interventions should the nurse recommend?
A. Avoid over-the-counter topical ointments
Over-the-counter topical ointments are generally not recommended for the treatment of herpes simplex outbreaks. It is best to consult with a healthcare provider for appropriate medication and treatment options
B. Cleanse skin eruptions with povidone-iodine
Herpes simplex is a viral infection that causes skin eruptions or lesions. To promote healing and prevent secondary infections, it is important to keep the affected area clean. Cleansing the skin eruptions with povidone-iodine, an antiseptic solution, can help reduce the risk of infection and promote healing.
C. Administer an antibiotic medication
Herpes simplex is a viral infection, and antibiotics are used to treat bacterial infections. Antibiotics are not effective against viral infections like herpes simplex.
D. Place disposable thermometers in the client's room
Placing disposable thermometers in the client's room is not directly related to the management of a herpes simplex outbreak. It is important to focus on interventions specific to the client's condition.
Full Explanation
B. Herpes simplex is a viral infection that causes skin eruptions or lesions. To promote healing and prevent secondary infections, it is important to keep the affected area clean. Cleansing the skin eruptions with povidone-iodine, an antiseptic solution, can help reduce the risk of infection and promote healing.
The other options are incorrect:
A. Over-the-counter topical ointments are generally not recommended for the treatment of herpes simplex outbreaks. It is best to consult with a healthcare provider for appropriate medication and treatment options.
C.Herpes simplex is a viral infection, and antibiotics are used to treat bacterial infections. Antibiotics are not effective against viral infections like herpes simplex.
D. Placing disposable thermometers in the client's room is not directly related to the management of a herpes simplex outbreak. It is important to focus on interventions specific to the client's condition.
A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?
A. Tell the client she should discuss this decision with her family.
While family involvement and support are important, the decision to stop dialysis ultimately rests with the client. It is the client's decision to make, and the nurse should respect the client's autonomy.
B. Discuss alternative treatment methods with the client.
If the client has made an informed decision to stop dialysis, it is not appropriate for the nurse to discuss alternative treatment methods at this point. The focus should be on supporting the client in their decision and providing comfort and care.
C. Ask the facility chaplain to visit the client.
Spiritual and emotional support can be valuable for clients facing end-of-life decisions, but it should be based on the client's preferences and requests. The nurse can offer spiritual support if desired but should not assume that it is necessary or appropriate in every case.
D. Support the client's decision to stop the treatment.
Stopping dialysis is a significant decision made by the client, and it is important for the nurse to respect and support the client's autonomy and right to make decisions about their own healthcare. The nurse should provide emotional support, validate the client's feelings and concerns, and ensure that the client has access to appropriate resources and support systems. It is not the nurse's role to persuade or encourage the client to continue or reconsider the decision.
Full Explanation
Stopping dialysis is a significant decision made by the client, and it is important for the nurse to respect and support the client's autonomy and right to make decisions about their own healthcare. The nurse should provide emotional support, validate the client's feelings and concerns, and ensure that the client has access to appropriate resources and support systems. It is not the nurse's role to persuade or encourage the client to continue or reconsider the decision.
The other options are incorrect:
Tell the client she should discuss this decision with her family: While family involvement and support are important, the decision to stop dialysis ultimately rests with the client. It is the client's decision to make, and the nurse should respect the client's autonomy.
Discuss alternative treatment methods with the client: If the client has made an informed decision to stop dialysis, it is not appropriate for the nurse to discuss alternative treatment methods at this point. The focus should be on supporting the client in their decision and providing comfort and care.
Ask the facility chaplain to visit the client: Spiritual and emotional support can be valuable for clients facing end-of-life decisions, but it should be based on the client's preferences and requests. The nurse can offer spiritual support if desired but should not assume that it is necessary or appropriate in every case.
A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation.
The nurse notes that the client's vagina and vulva are a purplish color. The nurse should document this finding as which of the following?
A. Chadwick's sign
Chadwick's sign is a characteristic change that occurs during pregnancy, specifically in the cervix, vagina, and vulva. It is characterized by a bluish or purplish discoloration of these areas.
B. Chloasma
It is a condition characterized by the development of dark patches on the skin, commonly referred to as "mask of pregnancy." Chloasma typically affects the face, particularly the cheeks, forehead, and upper lip. It is not associated with a change in colour in the vaginal or vulvar area.
C. Hegar's sign
It is a softening of the lower uterine segment that can be felt during a pelvic examination. It is not related to the colour changes in the vaginal or vulvar area.
D. Ballottement
It is a palpation technique used during a prenatal examination to assess the position of the foetus. It involves the examiner gently pushing against the uterus and feeling a rebound or "floating" movement of the foetus. It does not involve changes in the colour of the vaginal or vulvar area.
Full Explanation
Explanation
A. Chadwick’s sign
Chadwick's sign is a characteristic change that occurs during pregnancy, specifically in the cervix, vagina, and vulva. It is characterized by a bluish or purplish discoloration of these areas.
Chloasma in (option B) is incorrect because it is a condition characterized by the development of dark patches on the skin, commonly referred to as "mask of pregnancy." Chloasma typically affects the face, particularly the cheeks, forehead, and upper lip. It is not associated with a change in colour in the vaginal or vulvar area.
Hegar's sign in (option C) is incorrect because it is a softening of the lower uterine segment that can be felt during a pelvic examination. It is not related to the colour changes in the vaginal or vulvar area.
Ballottement in (option D) is incorrect because it is a palpation technique used during a prenatal examination to assess the position of the foetus. It involves the examiner gently pushing against the uterus and feeling a rebound or "floating" movement of the foetus. It does not involve changes in the colour of the vaginal or vulvar area.
