A client is ordered to receive a laxative by rectal suppository. How should the nurse position the client during the administration of the suppository?

A) Planning: The planning phase involves setting goals and determining the actions needed to achieve those goals. While the nurse may have planned to administer the medications through the nasogastric tube, the specific actions of crushing the tablets, mixing them with fluid, and administering them fall under a different phase. Therefore, planning is not the correct phase for the actions described.

B) Diagnosis: The diagnosis phase is when the nurse identifies and formulates nursing diagnoses based on data collected about the patient’s health status. The actions of preparing and administering medication do not fall under this phase, as diagnosis pertains to assessing health problems or needs.

C) Evaluation: Evaluation is the phase where the nurse assesses whether the goals or outcomes of the care plan have been met. The nurse would evaluate the effectiveness of the medication administration after it has been done, but the actual action of giving the medication is part of implementation, not evaluation.

D) Implementation: Implementation is the phase where the nurse carries out the planned interventions, including administering medications. In this case, the nurse is taking specific steps to prepare and administer the crushed tablets down the nasogastric tube, which is a direct action related to the care plan. This phase involves performing the tasks necessary to carry out the interventions that were decided during the
planning phase.

E) Assessment: Assessment involves collecting data about the client’s health status, such as physical examination, history, and vital signs. The actions taken to crush and administer medications are not part of the assessment phase, which focuses on gathering information, not delivering care.

A) Touch the tip of the bottle to the lacrimal duct: Touching the tip of the bottle to the lacrimal duct is not a recommended practice when administering eye drops. This could introduce bacteria into the eye or nose, leading to potential infection. The goal is to administer the drops without contamination, and the tip of the bottle should never touch the eye or any part of the face.

B) Apply pressure to inner canthus for 2 minutes: Applying pressure to the inner canthus (the corner of the eye near the nose) for about 2 minutes after administering ophthalmic drops is a key step when using systemically acting eye medications like propranolol. This helps to prevent the systemic absorption of the medication through the nasolacrimal duct, reducing the risk of systemic side effects such as bradycardia or hypotension. This step ensures that the medication stays localized in the eye.

C) Have client lie down or tilt the back of their head: While lying down or tilting the head back may help the client instil the drops more comfortably, it is not a required step for the proper absorption or effectiveness of eye drops. The key to effective administration lies in positioning the drop in the correct part of the eye and minimizing systemic absorption, which is achieved by applying pressure to the inner canthus, not necessarily by tilting the head.

D) Have client pull down their lower eyelid: Pulling down the lower eyelid is a standard step in administering eye drops, as it creates a small pocket to hold the drop. However, it does not specifically address the concern for reducing systemic absorption of a medication like propranolol. The primary step for preventing systemic effects is applying pressure to the inner canthus after administration, making this less relevant for this specific question.