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 to ensuring medication efficacy and preventing contamination or injury. The correct technique involves strict hygiene and avoiding direct contact between the dropper and the eye. **Why D is correct (the action needing further education):** Touching the dropper to the eye introduces a high risk of contamination. The dropper tip can pick up bacteria or debris from the eye, eyelashes, or surrounding skin, which may then contaminate the entire bottle of medication. Additionally, physical contact can cause microabrasions to the cornea or lead to accidental injury if the patient moves suddenly. Proper technique requires holding the dropper slightly above the eye (about 1-2 cm) to allow the drop to fall into the conjunctival sac without contact. **Why A is incorrect (acceptable action):** Setting the cap down in a non-contaminated manner (e.g., placing it on a clean tissue or holding it with the inner side facing upward) prevents exposure to dirt or microbes. Since the cap must be removed to administer drops, ensuring it remains clean is part of proper sterile technique. This action does not require correction. **Why B is incorrect (proper technique):** Instilling drops directly into the conjunctival sac (the pocket between the lower eyelid and eyeball) ensures optimal absorption and minimizes spillage. This area is less sensitive than the cornea, reducing discomfort. Dropping medication onto the cornea directly can cause irritation or reflexive blinking, leading to wasted medication. The client’s action here is correct. **Why C is incorrect (essential step):** Handwashing before handling eye drops is a fundamental infection control measure. Pathogens from unwashed hands can transfer to the eye or dropper, increasing the risk of infection (e.g., conjunctivitis). This step is non-negotiable in eye care and does not indicate a need for further teaching. **Key Takeaways for Proper Eye Drop Administration:** - Avoid dropper-to-eye contact to prevent contamination and injury. - Target the conjunctival sac for comfortable and effective delivery. - Maintain sterility by washing hands and handling the cap carefully. - Never touch the tip of the dropper to any surface, including the eye. Missteps like touching the dropper to the eye (D) compromise both safety and sterility, making it the clear indicator for additional client education. The other options (A, B, C) reflect correct practices that align with standard protocols for ophthalmic medication administration.

Correct Answer: A

Rationale: **Rationale:** **Choice A (Avoid home modification)** is the correct answer because it actively opposes measures that protect older adults from musculoskeletal injuries. Home modifications—such as installing grab bars, improving lighting, removing tripping hazards, and using non-slip mats—are essential for reducing fall risks and creating a safer living environment. Avoiding these modifications increases the likelihood of falls, fractures, and other musculoskeletal injuries, making this choice counterproductive to injury prevention. **Choice B (Wear a helmet when riding a bicycle)** is incorrect because helmet use is crucial for preventing head injuries, which can indirectly protect against musculoskeletal trauma. While the primary benefit of helmets is reducing traumatic brain injuries, they also minimize the risk of cervical spine and facial fractures. Encouraging protective gear aligns with injury prevention strategies, even if the direct focus is not solely on the musculoskeletal system. **Choice C (Osteoporosis screening)** is incorrect because osteoporosis screening is a proactive measure to identify bone density loss early, allowing for interventions like calcium supplementation, weight-bearing exercises, and medications to strengthen bones. Weak bones are more susceptible to fractures, even from minor falls. Early detection and management reduce fracture risk, directly supporting musculoskeletal health. **Choice D (Fall prevention)** is incorrect because fall prevention strategies—such as balance exercises, proper footwear, and assistive devices—are foundational to avoiding musculoskeletal injuries in older adults. Falls are a leading cause of fractures, sprains, and soft tissue damage in this population. Teaching fall prevention methods is evidence-based and directly supports musculoskeletal safety. **Conclusion:** The key distinction lies in recognizing that **Choice A** is the only option that actively undermines injury prevention, while the others promote protective measures. Home modifications are a well-documented, effective intervention, and discouraging them would leave older adults vulnerable to avoidable harm. The incorrect choices either directly or indirectly contribute to musculoskeletal safety, reinforcing their validity as helpful health teachings.

Correct Answer: B

Rationale: **Rationale:** **Correct Answer (B): The nurse cannot insert one finger between the cast and the skin** A properly applied cast should allow the nurse to insert one finger between the cast and the client’s skin to ensure there is adequate space to accommodate potential swelling. If the cast is too tight and prevents this, it indicates excessive pressure on the underlying tissues, increasing the risk of complications such as **compartment syndrome**—a medical emergency where increased pressure within a muscle compartment restricts blood flow, potentially causing tissue necrosis and permanent damage. This finding requires immediate intervention, such as cast loosening or bivalving, to prevent limb ischemia and nerve damage. **Incorrect Answers:** **A: The nurse assesses capillary refill of 2 seconds** A capillary refill time of **2 seconds is normal** and indicates adequate peripheral perfusion. Delayed capillary refill (>3 seconds) would be concerning, as it suggests poor circulation, possibly due to vascular compromise from swelling or cast tightness. Since this value is within the expected range (1–3 seconds), it does not indicate a problem. **C: The nurse finds 2+ pulses distal from the cast** The presence of **2+ pulses distal to the cast** (on a scale of 0–4+) confirms that arterial blood flow is intact. Absent or diminished pulses would raise concern for vascular compromise, but **2+ pulses are a reassuring finding** and suggest no immediate circulatory impairment. **D: The nurse does not observe any drainage** The absence of drainage is **expected** in a fresh cast (4 hours post-application). Drainage would only be concerning if the cast were older or if there were signs of bleeding, infection (e.g., foul odor, purulent discharge), or an open wound beneath the cast. Since no drainage is present, this finding is not indicative of a problem. **Key Takeaway:** The inability to insert a finger under the cast is the most critical finding because it suggests excessive constriction, which can lead to severe complications like compartment syndrome. Other findings (normal capillary refill, intact pulses, no drainage) are either expected or non-alarming in this scenario. Immediate action is required for a cast that is too tight to prevent irreversible tissue damage.

Correct Answer: a

Rationale: Deep vein thrombosis (DVT) is a significant postoperative complication, particularly following orthopedic surgeries like hip reduction and fixation, due to venous stasis, endothelial injury, and hypercoagulability (Virchow’s triad). Analyzing each option reveals why certain clients are at higher risk: **A: A client on birth control pills** - Correct. Estrogen-containing oral contraceptives increase clotting factors (e.g., fibrinogen, factors VII, VIII) and decrease anticoagulant proteins (e.g., protein S), creating a hypercoagulable state. Postoperative immobility exacerbates this risk. Studies show a 3- to 5-fold higher DVT risk in users, especially when combined with surgery. **B: A client who is immobile** - Correct. Immobility is a major DVT risk factor. Reduced muscle contraction in the lower extremities slows venous return, causing stasis. Post-hip surgery, clients often have limited mobility due to pain or restrictions, further increasing stasis-related clot formation. Early mobilization is critical to mitigate this. **C: A client on an anticoagulant** - Incorrect. Anticoagulants (e.g., heparin, warfarin) reduce clotting risk by inhibiting thrombin or vitamin K-dependent factors. While no medication eliminates DVT risk entirely, these clients are *less* likely to develop clots compared to untreated individuals. This option describes a protective, not risk, factor. **D: A client with dementia who has been wandering** - Incorrect. Wandering implies ambulation, which promotes venous return and reduces stasis. While dementia may pose other challenges, mobility lowers DVT risk. If the client were sedentary or restrained, the answer might differ, but wandering itself is protective. **Key Takeaways**: Hormonal therapy (A) and immobility (B) directly align with Virchow’s triad. Anticoagulants (C) reduce risk, and wandering (D) counters stasis. Understanding these mechanisms helps identify high-risk clients for prophylactic interventions like compression devices or early ambulation.

Correct Answer: A

Rationale: Neurovascular compromise occurs when there is impaired blood flow or nerve function to a specific area, often due to trauma, compression, or vascular injury. The correct answer, **A: Tingling**, is a classic symptom of neurovascular compromise because it indicates nerve irritation or ischemia (lack of blood flow). Nerves require adequate oxygenation and nutrients from blood flow to function properly. When compromised, sensory nerves malfunction, leading to abnormal sensations like tingling (paresthesia), numbness, or burning. This is a critical red flag in conditions like compartment syndrome, peripheral artery disease, or nerve compression syndromes, where early detection is vital to prevent permanent damage. **B: Strong pulses** is incorrect because robust, palpable pulses signify adequate blood flow, the opposite of neurovascular compromise. In compromised states, pulses may be weak, absent, or asymmetrical compared to the unaffected side. For instance, in arterial occlusion or compartment syndrome, distal pulses may diminish or disappear as pressure obstructs circulation. Strong pulses would rule out significant vascular impairment, making this choice inconsistent with the question. **C: Warm skin** is also incorrect because warmth typically indicates normal perfusion and healthy blood flow to the area. In neurovascular compromise, skin may become cool due to reduced circulation (e.g., in arterial insufficiency) or pale/mottled from ischemia. Warmth could persist in early stages (e.g., inflammation), but it isn’t a definitive sign of compromise. Over time, inadequate blood flow leads to temperature changes, but warmth alone doesn’t align with the diagnostic criteria for compromise. **D: Full range of motion** is incorrect because unrestricted movement suggests intact muscle and nerve function. Neurovascular compromise often causes pain with movement (e.g., passive stretching in compartment syndrome) or muscle weakness/paralysis due to nerve damage. For example, a patient with acute nerve compression may lose the ability to move a limb normally. Full range of motion contradicts the expected deficits in motor function seen in such conditions. Tingling is the only choice directly linked to the sensory nerve dysfunction or ischemia characteristic of neurovascular compromise. The other options either reflect normal function (strong pulses, warm skin, full motion) or are outright contradictory to the pathophysiology of the condition. Recognizing these distinctions is crucial for accurate clinical assessment and timely intervention.