A nurse is teaching a client who has a new prescription for tetracycline.
Which of the following information should the nurse include in the teaching?

The correct order is A, D, B, E, C.

Step 1 (A): Verify the clarity and color of the eye drops. The nurse must first ensure the medication is not expired, contaminated, or discolored before beginning the procedure to ensure client safety.

Step 2 (D): Tilt the client's head backward toward the ceiling. This positioning uses gravity to help the medication stay in the eye and makes the conjunctival sac more accessible for administration.

Step 3 (B): Pull the client's lower lid down with the nondominant hand. This action creates a small pocket (the conjunctival sac) where the medication can be safely deposited without touching the cornea.

Step 4 (E): Administer the prescribed number of drops. The nurse should hold the dropper about 1 to 2 cm above the conjunctival sac and instill the drops, being careful not to touch the eye or eyelashes with the dropper tip.

Step 5 (C): Apply gentle pressure to the client's punctum. This final step, called nasolacrimal occlusion, should be maintained for 1 to 2 minutes to prevent systemic absorption of the medication through the tear duct.

Choice A rationale: Documentation of admission data should occur as soon as possible after the information is obtained. Waiting until the end of the shift to chart a summary increases the risk of forgetting critical details and delays the communication of important findings to the rest of the healthcare team.

Choice B rationale: The Patient Self-Determination Act requires healthcare facilities to ask clients upon admission if they have advance directives, such as a living will or a durable power of attorney for healthcare. This information must be clearly documented in the medical record to ensure the client's end-of-life wishes are respected.

Choice C rationale: The nursing process begins with assessment, not evaluation. Evaluation is the final step where the nurse determines if goals were met. Charting should follow the chronological order of the nursing process: assessment, diagnosis, planning, implementation, and finally, evaluation.

Choice D rationale: Registered nurses are responsible for the initial admission assessment, which includes the first set of vital signs. While assistive personnel can take routine vitals later, the nurse should personally obtain and document the baseline admission data to ensure accuracy and clinical oversight.