Correct Answer: B

Rationale: When the client presses on the nasolacrimal duct while instilling eye drops, it temporarily blocks the lacrimal punctum. This obstruction helps prevent the systemic absorption of the medication by minimizing drainage into the nasolacrimal duct and subsequent systemic circulation. By following this technique, the client can enhance the localized effect of the eye drops and reduce the risk of systemic side effects.

Correct Answer: D

Rationale: Oxybutynin is an anticholinergic medication that can increase intraocular pressure. It is contraindicated in clients with glaucoma, as it can worsen the condition. Glaucoma is a condition characterized by increased intraocular pressure, and using Oxybutynin can further elevate this pressure, potentially leading to serious complications such as vision impairment or damage to the optic nerve.

Correct Answer: A

Rationale: Zolpidem is classified as Pregnancy Risk Category C. It is important for the client to inform the provider if they plan to become pregnant because the medication may need to be adjusted or changed to ensure the safety of the fetus. This communication allows for appropriate monitoring and adjustments to be made to the treatment plan.

Correct Answer: B

Rationale: In the given scenario, the correct answer is
B) Nasal congestion. Phenylephrine is a decongestant commonly used to relieve nasal congestion associated with conditions like sinusitis. Its primary mechanism of action is to constrict blood vessels in the nasal passages, leading to reduced swelling and congestion.
Therefore, the nurse should assess the client for any worsening or persistent nasal congestion as it could indicate a potential adverse effect of the medication.

Regarding the incorrect options:

A) Sedation: Phenylephrine is a sympathomimetic agent that typically causes stimulation rather than sedation.

C) Productive cough: Phenylephrine is not known to directly cause a productive cough.

D) Constipation: Constipation is not a common adverse effect associated with Phenylephrine use, as its effects are primarily localized to the nasal passages.

In an educational context, understanding the potential adverse effects of medications is crucial for nurses to provide safe and effective care to their clients. By knowing the expected outcomes of pharmacological interventions, nurses can monitor for adverse effects, intervene promptly, and collaborate with healthcare providers to optimize patient outcomes. This knowledge also underscores the importance of thorough assessment and patient education in medication management.

Correct Answer: C

Rationale: A serum potassium level of 5.2 mEq/L indicates hyperkalemia. Spironolactone is a potassium-sparing diuretic that can lead to potassium retention. The nurse should notify the provider and withhold the medication to prevent further elevation of potassium levels, which can result in serious cardiac complications.