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 D
Explanation
A. Securing electrical wires reduces tripping hazards and promotes safety.
B. Rubber-sole shoes provide better traction and reduce the risk of slips and falls.
C. Reduced visual acuity increases the risk of falls but not as much as taking antihypertensives do.
D. Taking an antihypertensive medication can be a potential fall risk, because it can cause hypotension and dizziness.
Correct Answer is ["A","C","E","F"]
Explanation
A. The nurse asks the client when was the last time they ate or drank anything, and verifies that they are fasting according to the preoperative instructions. Dietary intake is important because the client should have an empty stomach to prevent aspiration during anesthesia.
B. The oxygen saturation remains at 96% on room air, which is within the normal range. No immediate follow-up is needed based on this parameter.
C. The client's pain level has increased from 6 to 8 on a scale of 0 to 10. This increase in pain intensity requires further assessment and intervention to ensure adequate pain management before surgery.
D. The client's blood pressure remains relatively stable within normal limits.
However, the increase in pain intensity may impact blood pressure, and it's essential to monitor for any significant changes.
E. The allergies are important to identify because the client is allergic to shellfish, latex, and penicillin, which could cause anaphylaxis or other adverse reactions during surgery or anesthesia. The nurse should ensure that the client is wearing an allergy bracelet and that the surgical team is aware of the allergies.
F. The informed consent is essential to obtain before any invasive procedure. The nurse should verify that the client understands the risks, benefits, and alternatives of the surgery and that the consent form is signed and witnessed.
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