Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is planning to administer an ophthalmic medication to a client. Which of the following actions will
minimize systemic absorption of the medication?
A. Apply light pressure to the inner canthus just after instilling the eye drops
A) Apply light pressure to the inner canthus just after instilling the eye drops. Applying pressure to the inner canthus (the corner of the eye nearest the nose) helps occlude the nasolacrimal duct. This action reduces the systemic absorption of the medication by preventing it from draining into the nasal passages and subsequently into the systemic circulation, thus enhancing the local effect of the eye drops.
B. Wipe the eye from the inner to the outer canthus with a sterile saline-moistened coton ball
B) Wipe the eye from the inner to the outer canthus with a sterile saline-moistened cotton ball. While this action may help remove excess medication or discharge, it does not minimize systemic absorption. Instead, wiping the eye could inadvertently spread the medication to other areas, increasing the chance of absorption rather than reducing it.
C. Administer the medication drops directly into the lower conjunctival sac of each eye
C) Administer the medication drops directly into the lower conjunctival sac of each eye. While placing drops in the lower conjunctival sac is a standard practice for delivering ophthalmic medications, it does not directly influence systemic absorption. The main goal is to ensure adequate dosing in the eye, but systemic absorption can still occur if the drops drain into the nasolacrimal duct.
D. Wait 5 min after instillation before instilling the drops in the other eye
D) Wait 5 min after instillation before instilling the drops in the other eye. Waiting between instillations is good practice to prevent dilution of the first dose and to allow for absorption. However, this action does not significantly impact systemic absorption. It focuses more on ensuring that the first dose is effective before administering a second dose.
E. None
None
F. None
None
This question is an excerpt from Nurse Dive's nursing test bank - VATI PN Comprehensive Predictor 2020 Proctored Exam. Take the full exam now
Full Explanation
Answer: A. Apply light pressure to the inner canthus just after instilling the eye drops.
Rationale:
A) Apply light pressure to the inner canthus just after instilling the eye drops.
Applying pressure to the inner canthus (the corner of the eye nearest the nose) helps occlude the nasolacrimal duct. This action reduces the systemic absorption of the medication by preventing it from draining into the nasal passages and subsequently into the systemic circulation, thus enhancing the local effect of the eye drops.
B) Wipe the eye from the inner to the outer canthus with a sterile saline-moistened cotton ball.
While this action may help remove excess medication or discharge, it does not minimize systemic absorption. Instead, wiping the eye could inadvertently spread the medication to other areas, increasing the chance of absorption rather than reducing it.
C) Administer the medication drops directly into the lower conjunctival sac of each eye.
While placing drops in the lower conjunctival sac is a standard practice for delivering ophthalmic medications, it does not directly influence systemic absorption. The main goal is to ensure adequate dosing in the eye, but systemic absorption can still occur if the drops drain into the nasolacrimal duct.
D) Wait 5 min after instillation before instilling the drops in the other eye.
Waiting between instillations is good practice to prevent dilution of the first dose and to allow for absorption. However, this action does not significantly impact systemic absorption. It focuses more on ensuring that the first dose is effective before administering a second dose.
Similar Questions
A nurse is caring for several clients who are receiving well-child check-ups. The nurse should identify that the initial diphtheria, tetanus, and pertussis (DTaP) vaccine is indicated for which of the following clients?
A. A 2-month-old infant
The initial diphtheria, tetanus, and pertussis (DTaP) vaccine is indicated for a 2-month-old infant. The DTaP vaccine is typically administered as a series of doses starting in infancy to provide protection against diphtheria, tetanus, and pertussis (whooping cough). The recommended schedule for the DTaP vaccine includes a series of doses at 2, 4, and 6 months of age, with additional booster doses given later in childhood. Therefore, the first dose of DTaP is given to infants at 2 months of age.
B. A 4-month-old infant
By 4 months of age, the second dose of the DTaP vaccine should be administered, not the initial dose.
C. A 6-month-old infant
By 6 months of age, the third dose of the DTaP vaccine should be administered, not the initial dose.
D. A 15-month-old toddler
By 15 months of age, the toddler would have already received multiple doses of the DTaP vaccine as part of the recommended series. The initial dose is typically given earlier, at 2 months of age.
Full Explanation
The initial diphtheria, tetanus, and pertussis (DTaP) vaccine is indicated for a 2-month-old infant. The DTaP vaccine is typically administered as a series of doses starting in infancy to provide protection against diphtheria, tetanus, and pertussis (whooping cough).
The recommended schedule for the DTaP vaccine includes a series of doses at 2, 4, and 6 months of age, with additional booster doses given later in childhood. Therefore, the first dose of DTaP is given to infants at 2 months of age.
The other options are incorrect because:
b) A 4-month-old infant: By 4 months of age, the second dose of the DTaP vaccine should be administered, not the initial dose.
c) A 6-month-old infant: By 6 months of age, the third dose of the DTaP vaccine should be administered, not the initial dose.
d) A 15-month-old toddler: By 15 months of age, the toddler would have already received multiple doses of the DTaP vaccine as part of the recommended series. The initial dose is typically given earlier, at 2 months of age.
A nurse is collecting data from a newborn who has shoulder dystocia. The nurse should identify which of the following findings as an indication of pain?
A. Lip-smacking
A. Lip-smacking : Lip-smacking is not typically an indication of pain in newborns. It may be associated with hunger or neurological responses, but it does not directly indicate discomfort or pain caused by shoulder dystocia or other injuries.
B. Stiff posture
B. Stiff posture : A stiff posture can indicate pain in newborns, as they often exhibit hypertonicity or rigidity when experiencing discomfort. This response is a protective mechanism and may suggest the newborn is reacting to pain from potential nerve or tissue damage caused by shoulder dystocia.
C. Weak cry
C. Weak cry : While a weak cry may indicate neurological or respiratory distress, it is not a specific sign of pain. In the context of shoulder dystocia, a weak cry could reflect complications such as brachial plexus injury but does not directly signify the presence of pain.
D. Tongue-darting
D. Tongue-darting : Tongue-darting is more commonly associated with neurological issues or feeding difficulties rather than pain. It is not a typical behavioral response to discomfort or injury in newborns experiencing complications like shoulder dystocia.
Full Explanation
Answer: B. Stiff posture
Rationale:
A. Lip-smacking : Lip-smacking is not typically an indication of pain in newborns. It may be associated with hunger or neurological responses, but it does not directly indicate discomfort or pain caused by shoulder dystocia or other injuries.
B. Stiff posture : A stiff posture can indicate pain in newborns, as they often exhibit hypertonicity or rigidity when experiencing discomfort. This response is a protective mechanism and may suggest the newborn is reacting to pain from potential nerve or tissue damage caused by shoulder dystocia.
C. Weak cry : While a weak cry may indicate neurological or respiratory distress, it is not a specific sign of pain. In the context of shoulder dystocia, a weak cry could reflect complications such as brachial plexus injury but does not directly signify the presence of pain.
D. Tongue-darting : Tongue-darting is more commonly associated with neurological issues or feeding difficulties rather than pain. It is not a typical behavioral response to discomfort or injury in newborns experiencing complications like shoulder dystocia.
A nurse is preparing a client's insulin regimen. Which of the following insulins can be mixed? (Select all that
apply.)
A. Insulin aspart
Insulin aspart, regular insulin, and insulin lispro are all short-acting or rapid-acting insulins that can be mixed with other insulins.
B. Regular insulin
Insulin aspart, regular insulin, and insulin lispro are all short-acting or rapid-acting insulins that can be mixed with other insulins.
C. Insulin glargine
insulin glargine, and option d, insulin detemir, are long-acting insulins that should not be mixed with other insulins. These insulins have a different mechanism of action and are intended for basal or background insulin coverage.
D. Insulin detemir
Option c, insulin glargine, and option d, insulin detemir, are long-acting insulins that should not be mixed with other insulins. These insulins have a different mechanism of action and are intended for basal or background insulin coverage.
E. Insulin lispro
Insulin aspart, regular insulin, and insulin lispro are all short-acting or rapid-acting insulins that can be mixed with other insulins.