A nurse is preparing to administer an ophthalmic medication to a client.
Which of the following actions should the nurse plan to take?
Instill the ophthalmic medication directly on the client's cornea.
Ask the client to tightly squeeze their eyes shut after the instillation.
Clean the client's eye from the outer canthus to the inner canthus before instillation.
Apply pressure to the client's nasolacrimal duct after instillation.
The Correct Answer is D
Choice A rationale
Instilling ophthalmic medication directly on the cornea can cause irritation and discomfort. Medications should be administered in the conjunctival sac.
Choice B rationale
Asking the client to tightly squeeze their eyes shut after instillation can expel the medication, reducing its effectiveness. Gentle closing of the eyes is recommended.
Choice C rationale
Cleaning the eye from the outer canthus to the inner canthus is not the proper method. The correct method is to clean from the inner canthus to the outer canthus to avoid contaminating the inner eye.
Choice D rationale
Applying pressure to the nasolacrimal duct after instillation helps prevent the medication from draining into the nasolacrimal system, ensuring better absorption in the eye.
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Correct Answer is C
Explanation
Choice C rationale
The large intestine absorbs water and electrolytes from the remaining indigestible food matter, forming and eliminating solid waste (stool). This absorption process is vital for
maintaining the body's fluid and electrolyte balance.
Choice A rationale
The large intestine does not produce vitamin D; this occurs in the skin when exposed to sunlight. The large intestine’s primary functions are absorption and waste formation.
Choice B rationale
Preventing the reflux of food into the esophagus is the function of the lower esophageal sphincter, not the large intestine. The large intestine deals with waste processing rather than regulating esophageal function.
Choice D rationale
The secretion of digestive enzymes is a function of the pancreas, stomach, and small intestine. The large intestine does not secrete enzymes but focuses on absorbing water and electrolytes.
Correct Answer is C
Explanation
Choice A rationale
Replacing the external urinary catheter once each day is unnecessary. The catheter should be changed based on clinical judgment and manufacturer's guidelines to maintain hygiene.
Choice B rationale
Inserting the catheter into the client's urethra is incorrect for an external urinary catheter. External catheters are designed to be placed outside the body.
Choice C rationale
Applying a barrier cream to the client's perineal skin is correct. Barrier creams protect the skin from moisture and prevent skin breakdown and irritation caused by urine.
Choice D rationale
Connecting the catheter to continuous wall suction is not appropriate. External urinary catheters should be connected to a drainage bag for proper urine collection. .