A nurse is preparing to administer an ophthalmic medication to a client. Which of the following actions should the nurse plan take?

Apply pressure to the client's nasolacrimal duct after instillation.

Clean the client's eye from the outer canthus to the inner canthus before instillation.

Ask the client to tightly squeeze their eyes shut after the instillation.

Instill the ophthalmic medication directly on the client's cornea.

Answer and Explanation

The Correct Answer is A

A) Apply pressure to the client's nasolacrimal duct after instillation:
Applying gentle pressure to the nasolacrimal duct (located at the inner corner of the eye) after administering ophthalmic medication helps to reduce systemic absorption and increase the medication’s efficacy. This technique helps to prevent the medication from draining into the nasolacrimal duct and into the systemic circulation.

B) Clean the client's eye from the outer canthus to the inner canthus before instillation:
The eye should be cleaned from the inner canthus to the outer canthus to avoid transferring debris or infection from the outer parts of the eye to the inner areas. Cleaning from outer to inner canthus may cause contamination.

C) Ask the client to tightly squeeze their eyes shut after the instillation:
Asking the client to tightly squeeze their eyes shut is not recommended as it can cause the medication to be expelled or lead to increased systemic absorption. Instead, the client should gently close their eyes to allow for proper absorption.

D) Instill the ophthalmic medication directly on the client's cornea:
The medication should be administered into the conjunctival sac rather than directly on the cornea. Direct application to the cornea can cause irritation or damage.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A) Administer the medication using a 5/8-inch needle:
Ceftriaxone is typically administered using a longer needle to ensure proper injection into the muscle. A 5/8-inch needle is more suitable for subcutaneous injections rather than intramuscular (IM) injections.

B) Administer the medication using a Z-track technique:
The Z-track technique is appropriate for IM injections of medications like ceftriaxone, which can be irritating to tissues. This technique helps prevent the medication from leaking into the subcutaneous tissue and minimizes discomfort by creating a zigzag path in the muscle.

C) Administer the medication in the deltoid muscle:
Ceftriaxone is generally administered in larger muscle groups, such as the vastus lateralis or gluteus muscle, rather than the deltoid. The deltoid is more commonly used for vaccines or smaller volume injections.

D) Administer the medication at a 45° angle:
For IM injections, the needle should be inserted at a 90° angle to the skin. A 45° angle is more appropriate for subcutaneous injections.

A. Explain the purpose for the medications. B. Ask the client why he is refusing to take the medications. C. Tell the client the physician wants him to take the medications. D. Document that the client refuses the medications.

Correct Answer is B

Explanation

A) Explain the purpose for the medications:
While explaining the purpose of the medications is important, it is crucial first to understand the reason behind the client's refusal. This can help tailor the explanation to address specific concerns or misconceptions.

B) Ask the client why he is refusing to take the medications:
Asking the client about their reasons for refusing the medications is a critical first step. This approach allows the nurse to address any concerns, educate the client, and potentially find alternative solutions or treatments that the client may be more willing to accept.

C) Tell the client the physician wants him to take the medications:
Simply telling the client that the physician wants them to take the medications does not address the underlying reasons for the refusal. It is important to engage with the client to understand their perspective and address any concerns they might have.

D) Document that the client refuses the medications:
Documentation of the refusal is necessary for legal and medical records, but it should not be the initial action. Understanding the client’s reasons for refusal and attempting to address those reasons should be prioritized before documenting the refusal.

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A nurse is preparing to administer an ophthalmic medication to a client. Which of the following actions should the nurse plan take?

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