When applying ophthalmic ointments, the nurse should: (Select all that apply.)
fill only the center of the conjunctival sac.
remove excess ointment from the lid with a cotton ball.
remove gloves and perform hand hygiene.
ask the client to roll the eye around and from side to side.
ask the client to close the eyelids tightly to distribute ointment.
Correct Answer : C,D,E
A) Fill only the center of the conjunctival sac: This option is incorrect. When applying ophthalmic ointment, the ointment should be placed along the entire length of the conjunctival sac, not just the center, to ensure proper distribution and effectiveness.
B) Remove excess ointment from the lid with a cotton ball: This action is not recommended. Instead of using a cotton ball, which may introduce fibers or contaminants, excess ointment should be gently wiped away with a clean tissue or cloth if necessary. However, it is generally best to avoid excess application in the first place.
C) Remove gloves and perform hand hygiene: This option is correct. After applying the ointment, the nurse should remove gloves and perform hand hygiene to prevent any potential contamination and maintain proper infection control practices.
D) Ask the client to roll the eye around and from side to side: This is a correct action. Encouraging the client to roll their eyes helps distribute the ointment evenly across the surface of the eye, enhancing its effectiveness.
E) Ask the client to close the eyelids tightly to distribute ointment: This option is also correct. Closing the eyelids helps spread the ointment over the conjunctival surface, ensuring better coverage and absorption of the medication.
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Correct Answer is C
Explanation
A) Upward and back: This direction is appropriate for adults and older children but not for infants. The anatomy of an infant's ear canal requires a different approach for effective eardrop administration.
B) Upward and outward: This option is also incorrect for infants. Similar to option A, this technique does not effectively account for the anatomical differences in an infant's ear canal.
C) Downward and back: This is the correct action when administering eardrops to an infant. Pulling the auricle downward and back straightens the ear canal, allowing for better access to deeper structures and ensuring that the drops reach the intended area.
D) Downward and inward: This direction is not appropriate for straightening the ear canal. The correct technique is to pull downward and back to achieve the desired angle for effective administration of eardrops in infants.
Correct Answer is C
Explanation
A) A client who has a question about her daily medications: While it's important to address questions regarding medications, this client does not present an immediate clinical concern that requires urgent attention.
B) A client who needs discharge teaching about an antibiotic: Although discharge teaching is important, it is not an immediate priority compared to the potential instability of a client with chest pain.
C) A client who just received nitroglycerin for chest pain: This is the correct choice. A client who has received nitroglycerin needs to be closely monitored for its effects, including blood pressure and relief of chest pain. This situation is potentially critical, making it the highest priority for assessment.
D) A client who would like some acetaminophen (Tylenol) for a mild headache: While this request should be addressed, it is not as urgent as the need to assess the client who has recently received nitroglycerin. Managing a mild headache is less critical compared to monitoring a client with chest pain.