A nurse is preparing to administer ophthalmic drops to a client. Which of the following actions should the nurse take?
Tilt the client's head away from the side receiving the drops.
Instill the drops directly onto the cornea of the eye receiving the drops.
Rest the dominant hand on the client's forehead while instilling the drops.
Hold the medication dropper 0.5 cm (0.2 in) above the conjunctival sac.
The Correct Answer is C
A. Tilt the client's head away from the side receiving the drops: The client’s head should be tilted slightly back and toward the side receiving the drops, not away. Tilting away may cause the medication to run out instead of entering the conjunctival sac.
B. Instill the drops directly onto the cornea of the eye receiving the drops: The cornea is highly sensitive, and placing drops directly on it can cause pain, reflex blinking, or injury. Drops should be placed into the conjunctival sac to ensure comfort and proper absorption.
C. Rest the dominant hand on the client's forehead while instilling the drops: Resting the hand on the forehead stabilizes the dropper, preventing accidental injury if the client moves suddenly. This provides safety and accuracy when administering the medication.
D. Hold the medication dropper 0.5 cm (0.2 in) above the conjunctival sac: The dropper should be held about 1–2 cm above the sac to avoid touching the eye. Holding it too close increases the risk of contamination or accidental contact with the eye surface.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Please use your glucometer and show me the results.": Asking the client to demonstrate their technique provides the nurse with direct observation of how the client performs the skill. This allows the nurse to assess for errors in preparation, technique, or interpretation and ensures the client can perform self-monitoring correctly in their own home environment.
B. "Please tell me how long you have been using this glucometer.": Knowing the duration of glucometer use may provide some background information, but it does not show whether the client has the correct technique.
C. "These blood glucose results you've written down do not seem correct.": Telling the client their documented results seem wrong may come across as judgmental and could discourage openness. It also does not provide a clear assessment of the client’s ability to use the glucometer properly.
D. "Let me show you how to use this glucometer, so you can see if this is how you've been using it.": Demonstrating the procedure yourself first may help teach, but it does not initially allow the nurse to evaluate how the client is actually performing the task.
Correct Answer is D
Explanation
A. Client's present condition: The present condition is part of the “situation” portion of SBAR, describing why the nurse is contacting the provider. It is not included in the background section.
B. Questions for the provider regarding client care: Questions or recommendations are included in the “recommendation” portion of SBAR, not the background. They indicate what the nurse is requesting or suggesting for the client’s care.
C. Physical findings: Physical assessment data are reported in the “assessment” section of SBAR, providing objective information about the client’s current status rather than historical context.
D. Previous treatments: Previous treatments, medical history, and relevant background information are included in the “background” section. This information gives the provider context about the client’s condition and prior interventions.
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