The nurse has reviewed the Vital Signs at 1000.

Exhibits

Which of the following statements should the nurse include when reinforcing teaching to the client following the procedure? Select all that apply.

Rationale:

A. Wipe from the outer to the inner canthus after administering the drops: The correct technique is to wipe from the inner to the outer canthus to avoid introducing pathogens into the lacrimal system. Wiping in the wrong direction increases the risk of eye infections.

B. Position the child side-lying on the bed before administering the drops: Eye drops should be administered with the child in a supine or slightly reclined position. Side-lying positioning is more appropriate for ear drops and does not allow proper exposure of the conjunctival sac.

C. Apply pressure to the lacrimal punctum after administering the drops: Pressing the lacrimal punctum (inner corner of the eye) helps prevent systemic absorption of the medication by occluding the tear duct. This increases local efficacy and reduces the risk of systemic side effects, which is especially important in children.

D. Flush the eye with formal saline solution before administering the drops: Flushing with formal saline is unnecessary unless there is debris or discharge. Routine eye drop administration does not require pre-flushing..

Rationale:

A. Notify the unit manager: Informing the unit manager is necessary for institutional follow-up and quality assurance. However, it is not the immediate concern. Client safety and clinical status must be assessed first to determine if harm has occurred due to the error.

B. Collect data on the client: Assessing the client is the priority to determine if the excessive fluid has caused complications such as fluid overload, pulmonary edema, or changes in vital signs. Early identification of adverse effects is essential to guide further intervention.

C. Notify the provider: The provider should be informed after assessing the client so that appropriate medical interventions or monitoring can be initiated. Immediate data collection ensures the nurse can give accurate information about the client’s status.

D. Complete an incident report: Documentation of the error is an important step for institutional learning and accountability. However, it is not time-sensitive in the way client safety and assessment are and should follow after urgent clinical actions are taken.