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
Hypothermia is not commonly associated with diarrhea. Diarrhea typically leads to fluid loss and dehydration rather than changes in body temperature.
Choice B rationale
A rigid abdomen is not a typical finding for diarrhea. It may indicate other gastrointestinal issues, such as peritonitis, rather than dehydration caused by diarrhea.
Choice C rationale
Decreased bowel sounds are not typically expected with diarrhea, which often presents with increased bowel sounds due to increased motility.
Choice D rationale
Dehydration is a common finding in clients with diarrhea due to the excessive loss of fluids and electrolytes from frequent, loose stools. It can lead to symptoms such as dry mouth, reduced urine output, and dizziness.
Correct Answer is D
Explanation
Choice A rationale
Clients should be instructed to hold their breath for about 10 seconds after inhalation, not 2 seconds. This allows the medication to reach deeper into the lungs.
Choice B rationale
The MDI canister should not be washed after each use. Instead, it should be cleaned regularly to ensure proper functioning and avoid medication buildup.
Choice C rationale
Clients should be instructed to inhale the medication slowly and deeply over a few seconds, rather than quickly for 1 second. This ensures proper delivery of the medication to the lungs.
Choice D rationale
Shaking the MDI prior to administration is essential. This action mixes the medication evenly, ensuring that the correct dose is delivered with each puff.