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: The Health Care Proxy Does Not Go Into Effect Until I Am Incapable of Making Decisions
This statement is correct. A health care proxy, also known as a durable power of attorney for health care, only becomes active when the individual is no longer capable of making their own medical decisions. Until that point, the individual retains full control over their health care choices1.
Choice B: I Have to Choose a Family Member as My Health Proxy
This statement indicates a need for clarification. It is not necessary to choose a family member as a health care proxy. An individual can select any trusted person, whether a family member or a friend, to act as their health care proxy. The most important factor is that the chosen person understands the individual’s wishes and is willing to advocate for them2.
Choice C: I Can Change Who I Designate as My Health Care Proxy at Any Time
This statement is correct. An individual can change their designated health care proxy at any time, as long as they are still capable of making their own decisions. It is important to ensure that any changes are documented properly and that all relevant parties are informed of the change3.
Choice D: If I Become Incapacitated, End-of-Life Choices Will Be Made by My Proxy
This statement is correct. If an individual becomes incapacitated and is unable to make their own medical decisions, the health care proxy will step in to make decisions on their behalf, including end-of-life choices. The proxy should be well-informed about the individual’s preferences and values to make decisions that align with their wishes4.
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.
