the nurse is providing education to a client regarding the administration of eye drops which of the following actions indicates the need for further c

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. The nurse is providing education to a client regarding the administration of eye drops. Which of the following actions indicates the need for further client education?

A. The client instills the prescribed number of eye drops into the conjunctival sac
B. The client sets the cap to the eye drop container down in a manner that does not contaminate it
C. The client touches the administration dropper her to the eye
D. The client washes her hands before instilling the eye drops

Correct answer: C

Rationale:

2. A nurse is caring for an immobile client. What is the priority assessment of this client?

A. Palpate for edema
B. Auscultate for bowel sounds
C. Inspect the skin for injury
D. Auscultation of lung sounds

Correct answer: C

Rationale: Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.

3. What is the nurse's priority action for a client with compromised immunity?

A. Wash hands before entering the client's room
B. Take the client's vital signs every 4 hours
C. Determine whether it is temporary or permanent
D. Teach the family members to receive the flu shot annually

Correct answer: A

Rationale:

4. What is a sign of inadequate perfusion?

A. Intact sensation
B. Pallor in toes
C. Bounding pulses
D. Pink fingers

Correct answer: B

Rationale:

5. A client is diagnosed with glaucoma. The provider needs to determine if it is open-angle glaucoma or closed-angle glaucoma. What test does the nurse anticipate?

A. Ultrasonic imaging
B. Gonioscopy
C. Corneal staining
D. Electroretinography

Correct answer: B

Rationale: Gonioscopy is the appropriate test to anticipate in this scenario. It is used to distinguish between open-angle and closed-angle glaucoma by examining the angle where the iris meets the cornea. Choice A, ultrasonic imaging, is not typically used to differentiate between these types of glaucoma. Choice C, corneal staining, is used to detect corneal abrasions and defects, not to differentiate between types of glaucoma. Choice D, electroretinography, is a test that measures the electrical responses of various cell types in the retina and is not specific to differentiating between open-angle and closed-angle glaucoma.