Page 1996 - Saunders Comprehensive Review For NCLEX-RN

4. Give the medication as prescribed; the surgeon needs optimal
constriction of the pupil.

Answers

695. Answer: 3

Rationale: Hypotension, dizziness, nausea, diaphoresis, headache, fatigue,
constipation, and diarrhea are side and adverse effects of the medication. Nursing
interventions include monitoring the blood pressure for hypotension and assessing
the pulse for strength, weakness, irregular rate, and bradycardia. Options 1, 2, and 4
are not specifically associated with this medication.
Test-Taking Strategy: Note the strategic words, most appropriate. Use the ABCs—
airway, breathing, and circulation—to direct you to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Pharmacology: Eye and Ear: Glaucoma Medications
Health Problem: Adult Health: Eye: Glaucoma
Priority Concepts: Safety; Sensory Perception
Reference: Lewis et al. (2017), p. 381.

696. Answer: 1, 2, 3, 4

Rationale: To administer eye medications, the nurse should wash hands and put
gloves on. The client is instructed to tilt the head backward, open the eyes, and look
up. The nurse pulls the lower lid down against the cheekbone and holds the bottle
like a pencil with the tip downward. Holding the bottle, the nurse gently rests the
wrist of the hand on the client’s cheek and squeezes the bottle gently to allow the
drop to fall into the conjunctival sac. The client is instructed to close the eyes gently
and not to squeeze the eyes shut to prevent the loss of medication.
Test-Taking Strategy: Focus on the subject, the procedure for administering eye
drops. Use guidelines related to standard precautions and visualize this procedure.
This will assist in determining the correct interventions.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Skills: Medication Administration
Health Problem: N/A
Priority Concepts: Clinical Judgment; Safety
Reference: Ignatavicius, Workman, Rebar (2018), p. 966.

697. Answer: 1

Rationale: Before ear irrigation, the nurse should inspect the tympanic membrane
to ensure that it is intact. The irrigating solution should be warmed to 98.6° F (37.0°

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