Page 1997 - Saunders Comprehensive Review For NCLEX-RN

C), because a solution temperature that is not close to the client’s body temperature
will cause ear injury, nausea, and vertigo. The nurse should check the temperature of
the solution on the inner forearm. The affected side should be down following the
irrigation to assist in drainage of the fluid. When irrigating, a direct and slow steady
stream of irrigation solution is directed toward the wall of the canal, not toward the
eardrum. The client is positioned sitting, facing forward with the head in a natural
position; if the ear is faced upward, the nurse would not be able to visualize the
canal.
Test-Taking Strategy: Focus on the subject, the procedure for performing ear
irrigation. Think about the purpose of this procedure and keep safety in mind.
Visualizing each step and the information in the options will assist in eliminating the
incorrect ones.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Foundations of Care: Safety
Health Problem: N/A
Priority Concepts: Safety; Sensory Perception
Reference: Perry et al. (2018), p. 494.

698. Answer: 4

Rationale: Applying pressure on the nasolacrimal duct prevents systemic
absorption of the medication. Options 1, 2, and 3 will not prevent systemic
absorption.
Test-Taking Strategy: Focus on the subject, systemic effects. Eating and
swallowing are comparable or alike and are not related to the systemic absorption
of eye drops. Blinking vigorously to produce tearing may result in the loss of the
administered medication.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Foundations of Care: Client Teaching
Health Problem: N/A
Priority Concepts: Client Education; Safety
Reference: Lilley et al. (2017), p. 130.

699. Answer: 1

Rationale: When an eye drop and an eye ointment are scheduled to be
administered at the same time, the eye drop is administered first. The instillation of
two medications is separated by 3 to 5 minutes.
Test-Taking Strategy: Note the strategic word, best. Focus on the subject, the
guidelines for administering eye medications. Eliminate options 3 and 4 first because
of the words 15 minutes. Next, thinking about the consistency and absorption of a
drop versus ointment will direct you to the correct option.
Level of Cognitive Ability: Applying

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