A nurse at an ophthalmology clinic is providing teaching to a client who has open-angle glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the following instructions should the nurse provide?
Administer the medications 5 minutes apart.
Hold pressure on the conjunctival sac for 2 minutes following application of drops.
It is not necessary to remove contact lenses before administering medications.
Administer the medications by touching the tip of the dropper to the sclera of the eye.
The Correct Answer is A
Choice A: Administer the Medications 5 Minutes Apart
Administering the medications 5 minutes apart is crucial when using multiple eye drops. This practice ensures that each medication has enough time to be absorbed without being washed out by the subsequent drop. This is particularly important for medications like timolol and pilocarpine, which are used to manage intraocular pressure in glaucoma.
Choice B: Hold Pressure on the Conjunctival Sac for 2 Minutes Following Application of Drops
Holding pressure on the conjunctival sac (punctal occlusion) for 2 minutes after applying eye drops can help reduce systemic absorption and increase the local effect of the medication. However, this instruction is not as critical as the timing between administering different eye drops.
Choice C: It Is Not Necessary to Remove Contact Lenses Before Administering Medications
This statement is incorrect. Contact lenses should be removed before administering eye drops to prevent contamination and ensure proper absorption of the medication. The lenses can be reinserted after a sufficient amount of time has passed, usually around 15 minutes.
Choice D: Administer the Medications by Touching the Tip of the Dropper to the Sclera of the Eye
This statement is incorrect. The tip of the dropper should never touch the eye or any other surface to avoid contamination. The correct method is to hold the dropper above the eye and squeeze out the prescribed number of drops into the conjunctival sac.
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Correct Answer is B
Explanation
Choice A reason: Turn the client every 4 hours:
Regularly turning the client can help prevent pressure ulcers and improve overall circulation, but it is not the most effective measure specifically for preventing ventilator-associated pneumonia (VAP). While repositioning can help with lung expansion and secretion clearance, oral care is more directly related to reducing VAP risk.
Choice B reason: Brush the client’s teeth with a suction toothbrush every 12 hours:
Oral care is crucial in preventing VAP. Bacteria from the mouth can easily travel to the lungs, especially in intubated patients. Using a suction toothbrush helps remove dental plaque and secretions, reducing the bacterial load and the risk of infection. This practice is a key component of VAP prevention bundles.
Choice C reason: Provide humidity by maintaining moisture within the ventilator tubing:
While maintaining humidity is important to prevent drying of the respiratory mucosa and to help with secretion clearance, it does not directly reduce the risk of VAP. Proper humidification is necessary for patient comfort and respiratory function but is not a primary VAP prevention strategy.
Choice D reason: Position the head of the client’s bed in the flat position:
Positioning the head of the bed flat can increase the risk of aspiration, which is a significant risk factor for VAP. The head of the bed should be elevated to 30-45 degrees to reduce the risk of aspiration and promote better lung expansion.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A: Type and match for 2 units of packed RBCs
This option is not typically part of the initial management of sepsis. Typing and matching for blood transfusion is generally reserved for patients who are experiencing significant blood loss or severe anemia. In this case, the patient’s hemoglobin and hematocrit levels are within normal ranges, indicating that a blood transfusion is not immediately necessary. The primary focus in the first hour of sepsis management is to stabilize the patient through fluid resuscitation, infection control, and monitoring vital signs.
Choice B: Rapidly administer 30 mL/kg of normal saline
Rapid fluid resuscitation is a critical component of sepsis management. Administering 30 mL/kg of normal saline helps to restore intravascular volume, improve tissue perfusion, and prevent organ failure. This intervention is particularly important in patients with hypotension or elevated lactate levels, as it helps to maintain adequate blood pressure and oxygen delivery to tissues. The Surviving Sepsis Campaign guidelines recommend this approach to stabilize patients and prevent further complications.
Choice C: Measure lactate level
Measuring lactate levels is essential in the early management of sepsis. Elevated lactate levels indicate tissue hypoperfusion and anaerobic metabolism, which are hallmarks of sepsis and septic shock. Monitoring lactate levels helps to assess the severity of the condition and guide further treatment decisions. The Surviving Sepsis Campaign guidelines emphasize the importance of measuring lactate levels within the first hour of sepsis recognition. If the initial lactate level is elevated, it should be remeasured to evaluate the effectiveness of the interventions.
Choice D: Obtain blood cultures
Obtaining blood cultures before administering antibiotics is crucial for identifying the causative pathogen and tailoring antibiotic therapy. Blood cultures help to determine the source of infection and guide appropriate antimicrobial treatment. Early identification and targeted therapy are essential for improving patient outcomes in sepsis. The Surviving Sepsis Campaign guidelines recommend obtaining blood cultures as part of the initial management of sepsis.
Choice E: Obtain a wound culture
Obtaining a wound culture is important in this case because the patient has a wound with purulent drainage, which could be a potential source of infection. Identifying the specific pathogen responsible for the wound infection allows for targeted antibiotic therapy, which is more effective than broad-spectrum antibiotics. This intervention helps to control the source of infection and prevent further complications. The Surviving Sepsis Campaign guidelines support source control measures, including obtaining wound cultures, as part of the initial management of sepsis.
