A nurse is administering multiple types of ophthalmic drops to a client. Which of the following actions should the nurse take?
Hold the dropper 3 cm (1.2 in) away from the client's eye.
Massage the client's eyelids for 20 seconds after instillation.
Wait 5 min between the administration of each medication.
Ask the client to close their eyes tightly after instilling each medication.
The Correct Answer is C
A. The dropper should be held about 1 cm (0.4 in) away from the eye to avoid touching or injuring the eye or contaminating the dropper tip.
B. Massaging the eyelids after instillation is not a standard practice and may cause discomfort or injury to the eye.
C. Administering multiple ophthalmic medications requires a sufficient interval between doses to prevent interactions and ensure effectiveness.
D. Asking the client to close their eyes tightly may squeeze out some of the medication or increase intraocular pressure.
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Related Questions
Correct Answer is C
Explanation
A. Sterile gloves are not necessary for collecting sputum specimens. Clean gloves are typically sufficient.
B. Sputum specimens should be collected in a sterile container to prevent contamination.
C. Early morning specimens are preferred due to increased sputum production from the overnight accumulation of secretions.
D. Mouthwash may contain substances that interfere with sputum culture results, so specimens should be collected before mouthwash use.
Correct Answer is D
Explanation
A. With the Z-track method, the skin is pulled laterally or to the side before the needle is inserted and released after the injection is administered to ensure the medication remains within the muscle and does not leak into the subcutaneous tissue.
B. The angle of insertion for intramuscular injections can vary depending on factors such as the client's body habitus and the length of the needle but is typically 90 degrees.
C. The needle should be withdrawn slowly and steadily to minimize tissue trauma and prevent medication leakage.
D. The Z-track method involves pulling the skin laterally or to the side before inserting the needle to create a zigzag pathway for the medication. This helps seal the needle track after the injection, reducing the risk of medication leakage into subcutaneous tissues.
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