the nurse is teaching the client how to administer eye drops which of these actions indicates the need for further client education

ATI RN

Multi Dimensional Care | Final Exam

1. The nurse Is teaching the client how to administer eye drops. Which of these actions indicates the need for further client education?

A. The client sets the cap down in a manner that does not contaminate it.
B. The client drops the prescribed number of drops into the conjunctival sac
C. The client washes their hands before instilling the drops
D. The client ensures that they touch the administration dropper to the eye

Correct answer: D

Rationale: Touching the dropper to the eye contaminates it and can lead to infection.

2. 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:

3. The nurse is caring for a 65-year-old client and notes a temperature of 101°F. How does the nurse interpret this finding?

A. Hyperthermia
B. A cold environment
C. Normal
D. Hypothermia

Correct answer: A

Rationale: A temperature of 101°F is indicative of hyperthermia, which is an elevated body temperature. Hyperthermia is commonly associated with fever or environmental factors such as excessive heat exposure. Choice B, 'A cold environment,' is incorrect as hyperthermia refers to elevated body temperature, not a cold environment. Choice C, 'Normal,' is incorrect as a temperature of 101°F is above the normal range for body temperature. Choice D, 'Hypothermia,' is incorrect as hypothermia refers to a low body temperature, not an elevated one.

4. What is a negative effect of immobility on the cardiovascular system?

A. Increased high density lipoprotein
B. Increased circulation
C. Increased pumping action of the heart
D. Venous stasis

Correct answer: D

Rationale: Venous stasis is a negative effect of immobility on the cardiovascular system. Immobility can lead to blood pooling in the veins due to lack of movement, increasing the risk of blood clots. Choices A, B, and C are incorrect because immobility does not lead to an increase in high density lipoprotein, circulation, or the pumping action of the heart.