A nurse is planning to administer an ophthalmic medication to a client. Which of the following actions will
minimize systemic absorption of the medication?
Apply light pressure to the inner canthus just after instilling the eye drops
Wipe the eye from the inner to the outer canthus with a sterile saline-moistened coton ball
Administer the medication drops directly into the lower conjunctival sac of each eye
Wait 5 min after instillation before instilling the drops in the other eye
None
None
The Correct Answer is A
Answer: A. Apply light pressure to the inner canthus just after instilling the eye drops.
Rationale:
A) Apply light pressure to the inner canthus just after instilling the eye drops.
Applying pressure to the inner canthus (the corner of the eye nearest the nose) helps occlude the nasolacrimal duct. This action reduces the systemic absorption of the medication by preventing it from draining into the nasal passages and subsequently into the systemic circulation, thus enhancing the local effect of the eye drops.
B) Wipe the eye from the inner to the outer canthus with a sterile saline-moistened cotton ball.
While this action may help remove excess medication or discharge, it does not minimize systemic absorption. Instead, wiping the eye could inadvertently spread the medication to other areas, increasing the chance of absorption rather than reducing it.
C) Administer the medication drops directly into the lower conjunctival sac of each eye.
While placing drops in the lower conjunctival sac is a standard practice for delivering ophthalmic medications, it does not directly influence systemic absorption. The main goal is to ensure adequate dosing in the eye, but systemic absorption can still occur if the drops drain into the nasolacrimal duct.
D) Wait 5 min after instillation before instilling the drops in the other eye.
Waiting between instillations is good practice to prevent dilution of the first dose and to allow for absorption. However, this action does not significantly impact systemic absorption. It focuses more on ensuring that the first dose is effective before administering a second dose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should atend to the client who has COPD and dementia and was agitated during the night shift first. This client may be experiencing respiratory distress or other complications related to their COPD and requires immediate assessment and intervention.
a) A client who has heart failure and is incontinent of urine requires atention, but their needs are not as urgent as those of the client with COPD and agitation.
c) A client who had a hip arthroplasty 10 days ago and reports pain with ambulation requires atention, but their needs are not as urgent as those of the client with COPD and agitation.
d) A client who had a cerebrovascular accident 6 months ago and reports constipation requires attention, but their needs are not as urgent as those of the client with COPD and agitation.
Correct Answer is C
Explanation
Answer: (C) The client is not grimacing
Rationale:
A) The client's blood pressure has been reduced:
While morphine can lower blood pressure due to its vasodilatory effects, a reduction in blood pressure is not necessarily a primary indicator of a therapeutic response to pain relief. It is more important to assess pain relief directly through the client's subjective experience and behavior rather than focusing on vital signs alone.
B) The client exhibits diaphoresis:
Diaphoresis, or sweating, can occur as a side effect of morphine administration but does not indicate that the medication is effectively relieving pain. In fact, diaphoresis might signal an adverse reaction or discomfort rather than a therapeutic effect.
C) The client is not grimacing:
The absence of grimacing suggests that the client's pain has decreased, which is a direct indicator of a therapeutic response to morphine. Observing a reduction in pain-related behaviors, such as grimacing, is a key assessment for determining the effectiveness of pain management in postoperative clients.
D) The client has an elevated heart rate:
An elevated heart rate may be a sign of unresolved pain or a side effect of morphine but is not a clear indicator of pain relief. Effective pain management with morphine typically results in a decrease in sympathetic nervous system responses, such as a high heart rate, rather than an increase.
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