A nurse is planning to administer an ophthalmic medication to a client. Which of the following actions will minimize systemic absorption of the medication?

A. 2+ deep tendon reflex: A reflex rating of 2+ is normal and indicates adequate neuromuscular function. In a client receiving magnesium sulfate, this suggests that magnesium levels are within the therapeutic range and are not causing toxicity.

B. Facial flushing: Facial flushing is a common side effect of magnesium sulfate due to vasodilation. While uncomfortable, it is not dangerous and typically does not require intervention unless accompanied by other signs of toxicity.

C. Respiratory rate 13/min: A respiratory rate above 12/min is generally considered within normal limits for adults. Magnesium toxicity becomes concerning when the respiratory rate drops below 12/min, indicating central nervous system depression.

D. Urine output 20 mL/hr: Magnesium sulfate is excreted primarily by the kidneys, and low urine output (<30 mL/hr) increases the risk of magnesium accumulation and toxicity. Reporting this finding allows the provider to adjust the infusion rate or evaluate renal function to prevent serious complications.

A. Pour liquid by holding the bottle with the label facing the sterile field: When pouring solutions onto a sterile field, the label should face the nurse’s hand, not the sterile field. This prevents the liquid from running down the bottle and obscuring or washing off the label, which maintains accurate identification of the solution while protecting the sterile field.

B. Prepare the sterile field 5 cm (2 in) below the level of the waist: The sterile field should be set up at or above waist level to prevent accidental contamination. Positioning it below waist level increases the risk of droplets, contact with nonsterile surfaces, or accidental touches, compromising sterility.

C. Pour liquids from 10 to 15 cm (4 to 6 in) above the sterile field: Maintaining this distance ensures that the fluid is poured without splashing or touching the sterile field with the bottle, which reduces contamination risk. This technique balances control and safety while preserving sterility during preparation or dressing changes.

D. Open the outermost flap of the wrapper toward the body: The outermost flap should be opened away from the body to prevent reaching over the sterile field, which could result in accidental contamination. Opening toward the body increases the chance that clothing or hands might contact the sterile surface.