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 A rationale
Documenting the medication administration is important but should be done after administering the medication. Documentation ensures proper tracking and accountability but does
not address immediate patient safety concerns like checking for allergies.
Choice B rationale
Mixing the medication at the client's bedside may ensure that the medication is prepared correctly and the client receives it promptly, but it doesn't address the critical step of
ensuring the client's safety by checking for allergies first.
Choice C rationale
Checking the client for allergies is crucial before administering any medication, including powdered forms. Allergic reactions can be severe or life-threatening, so it’s essential to
ensure that the client isn’t allergic to the medication. This step ensures the safety and well-being of the client and prevents potential adverse reactions.
Choice D rationale
Determining the client's response to the medication is important for assessing the medication's effectiveness and identifying any adverse reactions, but it occurs after administration.
Checking for allergies precedes all these steps to prevent any initial harm.
Correct Answer is A
Explanation
Choice A rationale
Reflex incontinence is caused by neurological impairment or damage, such as spinal cord injury, which results in a loss of voluntary control over urination. The bladder muscle contracts involuntarily, causing urine leakage.
Choice B rationale
Overflow incontinence occurs when the bladder cannot empty properly, leading to frequent or constant dribbling of urine. It is not typically associated with nerve damage from spinal cord injury.
Choice C rationale
Stress incontinence is caused by physical movement or activity—such as coughing, sneezing, or heavy lifting—that puts pressure on the bladder, leading to urine leakage. It is not related to nerve damage or neurological conditions.
Choice D rationale
Urge incontinence is characterized by a sudden, intense urge to urinate, followed by involuntary urine leakage. It is usually caused by an overactive bladder or other conditions affecting bladder function, but not directly by nerve damage from spinal cord injury.