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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. While educating the client about the benefits of surgery is important, it is not appropriate to dismiss the client's concerns in this situation.

B. It is important to respect the client's autonomy and decision-making process. If the client expresses a desire to reconsider the surgery, their wishes should be respected.
C. The nurse should respect the client's decision and communicate their wishes to the surgical team for further discussion and decision-making.
D. While reassurance is important, it should be provided in a way that acknowledges and respects the client's concerns and decisions.

A. Bounding pulses B. Restlessness C. Warm skin D. Brisk capillary refill

Correct Answer is B

Explanation

A. Active bleeding with significant blood is characterized by weak and thread pulses and not bounding pulses.
B. Restlessness can be a sign of hypovolemia and decreased tissue perfusion, which may occur with active bleeding.
C. Warm skin may not necessarily indicate active bleeding but rather normal thermoregulation or vasodilation.
D. Brisk capillary refill is a sign of adequate peripheral perfusion and is not typically associated with active bleeding which is characterized by delayed capillary refill.

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A nurse is administering multiple types of ophthalmic drops to a client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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