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 D
Explanation
Choice A rationale
Aging usually leads to a decrease in muscle tone of the bowel rather than an increase, which can result in slower bowel movements and constipation.
Choice B rationale
Gastric acid production tends to decrease with age, not increase. This can affect the digestion and absorption of nutrients, and also increase the risk of stomach infections.
Choice C rationale
The pH of the stomach tends to become less acidic (increase) as one ages, not decrease. This is often due to the reduced production of gastric acid.
Choice D rationale
Decreased intestinal peristalsis is a common physiological change in older adults. This slowing down of the intestinal movements can lead to constipation and other digestive issues.
Correct Answer is C
Explanation
Choice A rationale
The end of the stoma is typically not painful after the procedure. Pain at the stoma site could indicate complications such as infection or ischemia.
Choice B rationale
A healthy stoma should be pink or red in color. A purple color could indicate compromised blood flow or other complications that require medical attention.
Choice C rationale
The stoma is typically placed in the right lower abdomen to allow for easier management and care, as it is usually associated with the terminal ileum.
Choice D rationale
After an ileostomy, the stool is usually liquid to semi-formed, not solid, because the colon, which absorbs water to solidify stool, is bypassed.