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

Correct Answer: D

Rationale: Administering eye drops correctly is critical for both medication efficacy and infection prevention. The action described in **Choice D (touching the dropper to the eye)** clearly indicates a need for further education because it introduces contamination risks. The dropper tip should never contact the eye, eyelids, or any other surface, as this can introduce bacteria or other pathogens into the medication bottle, leading to potential infections like conjunctivitis or keratitis. Proper technique involves holding the dropper close to the eye (about an inch away) without making direct contact to maintain sterility. **Choice A (setting the cap down without contaminating it)** is correct and does not require additional teaching. Placing the cap in a clean, dry location (e.g., upside down on a tissue) prevents contamination, ensuring the medication remains sterile. This demonstrates the client’s understanding of aseptic technique. **Choice B (dropping medication into the conjunctival sac)** is also correct. The conjunctival sac, the pocket formed by pulling down the lower eyelid, is the ideal location for instilling drops. This ensures proper absorption and minimizes spillage. The client’s ability to target this area correctly shows they have been taught the proper administration technique. **Choice C (washing hands before instilling drops)** reflects proper hygiene and is essential to prevent transferring pathogens from the hands to the eye. Handwashing reduces the risk of infection, and the client’s adherence to this step indicates they are following best practices. In summary, **Choice D** is the only option that reveals a critical error in technique, as it compromises sterility and increases infection risk. The other choices (A, B, and C) demonstrate correct practices that align with standard eye drop administration protocols. Clients must be reminded to avoid touching the dropper to the eye or any surface to maintain medication safety and effectiveness. Correcting this behavior is crucial to ensure therapeutic outcomes and prevent complications.

Correct Answer: A

Rationale: **Rationale:** **Correct Answer (A: Avoid home modification)** Avoiding home modifications is counterproductive to preventing musculoskeletal injuries in older adults. Home modifications—such as installing grab bars in bathrooms, improving lighting, removing tripping hazards, and adding stair railings—are proven strategies to reduce fall risks and subsequent fractures or sprains. Falls are a leading cause of musculoskeletal injuries in older adults, and modifications create a safer living environment. Ignoring these adaptations increases the likelihood of accidents, making this choice the least helpful advice. **Incorrect Answers:** **B: Wear a helmet when riding a bicycle** This is a valid preventive measure. While cycling, older adults are at risk of falls or collisions that could lead to fractures or traumatic injuries. A helmet protects against head injuries, which can indirectly prevent musculoskeletal harm by reducing the impact force transmitted to the neck, spine, and limbs. Though cycling may be less common in older adults, safety gear is still crucial for those who engage in such activities. **C: Osteoporosis screening** Osteoporosis screening is critical for older adults because it identifies bone density loss, a major risk factor for fractures. Early detection allows for interventions (e.g., calcium supplementation, weight-bearing exercises, or medications) that strengthen bones and reduce fracture risks. Since weakened bones exacerbate injury severity, screening directly contributes to musculoskeletal injury prevention. **D: Fall prevention** Fall prevention strategies (e.g., balance exercises, proper footwear, and medication reviews) are essential for older adults. Falls often result in fractures, dislocations, or soft tissue injuries, particularly in those with osteoporosis or muscle weakness. Proactive measures significantly lower injury risks, making this a highly effective teaching point. In summary, while options B, C, and D actively promote musculoskeletal safety, option A undermines injury prevention by discouraging necessary environmental adaptations.

Correct Answer: B

Rationale: Let’s analyze each option in detail to understand why **B** is the correct answer and why the others are incorrect. **Option B: The nurse cannot insert one finger between the cast and the skin** This is the correct answer because a properly applied cast should allow for slight swelling while maintaining immobilization. If the nurse cannot insert a finger between the cast and the skin, it indicates that the cast is **too tight**, which can lead to serious complications such as **compartment syndrome**. This condition occurs when increased pressure within a confined space (caused by swelling) restricts blood flow, potentially leading to tissue necrosis and permanent damage. Nurses must ensure there is enough space to accommodate expected post-cast swelling, and inability to insert a finger is a critical warning sign requiring immediate intervention, such as cast loosening or replacement. **Option A: The nurse assesses capillary refill of 2 seconds** A capillary refill time of **2 seconds is normal** and indicates adequate peripheral circulation. Delayed capillary refill (>3 seconds) would be concerning, as it suggests poor perfusion, possibly due to vascular compression or compromised circulation. Since 2 seconds falls within the expected range, this finding does not raise immediate concerns and is not the correct answer. **Option C: The nurse finds 2+ pulses distal from the cast** A **2+ pulse** is considered **normal** and indicates sufficient blood flow to the extremity. Diminished or absent pulses (0 or 1+) would be problematic, signaling possible vascular compromise, such as arterial occlusion or severe swelling obstructing circulation. Since 2+ pulses are expected in a healthy assessment, this finding does not warrant concern. **Option D: The nurse does not observe any drainage** The absence of drainage is typically **a normal and expected finding** in a fresh cast (unless there was an open wound pre-cast application). Drainage or foul odor would suggest complications like **infection or hemorrhage**, requiring further evaluation. Since no drainage is not a worrisome sign, this option is incorrect. In summary, **B** is the only choice indicating a potential **dangerous complication (cast tightness leading to impaired circulation or compartment syndrome)**, whereas the other findings are either normal or do not suggest immediate risk. Proper cast assessment prioritizes checking for tightness, circulation, sensation, and movement—any restriction in these areas must be addressed promptly to prevent permanent damage.

Correct Answer: D

Rationale: Immobility negatively impacts the cardiovascular system by disrupting normal hemodynamics, and the most significant consequence is **venous stasis (D)**. When a person is immobile for prolonged periods, skeletal muscle contractions—which normally assist venous return by compressing veins and propelling blood toward the heart—are minimized. This leads to blood pooling in the lower extremities, increasing venous pressure and causing stasis. Stasis raises the risk of **deep vein thrombosis (DVT)** due to sluggish blood flow, endothelial damage, and hypercoagulability. Additionally, immobility reduces the effectiveness of the venous valve system, further impairing circulation and exacerbating fluid accumulation in dependent tissues. **A ("Increased high-density lipoprotein")** is incorrect because immobility typically correlates with **reduced** HDL levels, not an increase. Physical inactivity is associated with unfavorable lipid profiles, including lower HDL (the "good" cholesterol) and higher LDL and triglycerides. HDL helps remove excess cholesterol, and its reduction worsens cardiovascular health. Immobility promotes metabolic dysregulation, contributing to atherosclerosis, contrary to the premise of this option. **B ("Increased circulation")** is incorrect because immobility **decreases** circulation. Normal circulation relies on movement—both physical activity and positional changes—to promote venous return via the muscle pump mechanism. Immobility stagnates blood flow, reducing cardiac output over time and impairing tissue perfusion. This can lead to complications like orthostatic hypotension (due to reduced vascular tone) and dependent edema, directly opposing the claim of improved circulation. **C ("Increased pumping action of the heart")** is incorrect because immobility **weakens** cardiac function. Prolonged inactivity reduces cardiac workload, leading to **cardiovascular deconditioning**. The heart’s pumping efficiency declines as stroke volume and cardiac output decrease due to reduced demand. Over time, this can cause myocardial atrophy (shrinking of heart muscle) and decreased aerobic capacity, the opposite of enhanced pumping action. The heart adapts to lower activity levels by becoming less efficient, not more. In summary, venous stasis (D) is the only plausible consequence of immobility, while the other choices describe outcomes that are either physiologically implausible (B, C) or opposite to the expected metabolic effects (A). The cardiovascular system relies on movement to maintain homeostasis, and immobilization disrupts this balance, posing significant risks like DVT, deconditioning, and impaired circulation.

Correct Answer: B

Rationale: **Rationale:** **Correct Answer (B): Reducing caffeine intake can decrease the risk of osteoporosis.** Caffeine has a mild diuretic effect, increasing calcium excretion through urine. Over time, excessive caffeine consumption (typically >3–4 cups of coffee per day) may contribute to decreased bone mineral density, particularly if calcium intake is insufficient. While caffeine alone is not a primary cause of osteoporosis, moderation helps preserve calcium balance, supporting bone health. **Incorrect Answer (A): Avoiding vitamin D would increase, not decrease, osteoporosis risk.** Vitamin D is essential for calcium absorption in the intestines. Without sufficient vitamin D, the body cannot effectively utilize dietary calcium, leading to weakened bones. Avoiding vitamin D would exacerbate bone loss, directly contradicting osteoporosis prevention strategies. **Incorrect Answer (C): Decreasing alcohol intake is correct, but the question asks for the nurse’s incorrect statement.** Excessive alcohol impairs osteoblast function (bone-forming cells) and interferes with calcium and vitamin D metabolism, increasing osteoporosis risk. However, this option is factually accurate, so its inclusion here suggests a misinterpretation of the question. If the question intended to identify only incorrect statements, this would not fit. **Incorrect Answer (D): Reducing protein intake would harm bone health.** Adequate protein is crucial for maintaining bone matrix integrity. Low protein intake is associated with reduced bone density and slower healing of fractures. While excessive protein without sufficient calcium may pose risks, protein restriction is not a recommended osteoporosis prevention strategy. **Key Takeaways:** - **Bone health requires balance:** Calcium, vitamin D, and protein are critical; caffeine and alcohol should be moderated. - **Misleading choices:** Avoiding vitamin D or protein directly undermines bone strength, while alcohol reduction (though correct) does not align with the question’s framing if seeking incorrect statements. - **Context matters:** The question likely tests recognition of harmful advice (A and D) versus beneficial actions (B and C), but assuming it requests incorrect statements, B stands alone as the accurate selection. **Clarifying Nuances:** - Caffeine’s effect is dose-dependent; moderate intake with adequate calcium may not pose significant risk. - Alcohol’s harm is dose-dependent, but abstinence is not required—moderation is key. - Vitamin D and protein are non-negotiable for bone health; their restriction is never advised. This rationale ensures students understand not just the correct answer but the physiological principles underlying each option, empowering them to apply this knowledge in clinical judgment.