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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Correct Answer is B

Explanation

A) Withholding the medication if the heart rate is above 100/min:
Digoxin is typically withheld if the heart rate is below 60 beats per minute (bradycardia) rather than above 100 beats per minute. In fact, a heart rate above 100/min may indicate tachycardia, which is not necessarily a contraindication for administering digoxin.

B) Evaluating the client for nausea, vomiting, and anorexia:
These symptoms are signs of digoxin toxicity. Evaluating for these symptoms is crucial as part of monitoring for adverse effects. Clients experiencing these symptoms may need their digoxin levels checked and potentially adjusted.

C) Instructing the client to eat foods that are low in potassium:
Digoxin therapy requires adequate potassium levels for effectiveness. Clients should be encouraged to consume foods high in potassium to prevent hypokalemia, which can increase the risk of digoxin toxicity.

D) Measuring apical pulse rate for 30 seconds before administration:
The apical pulse should be measured for a full minute to accurately assess the heart rate before administering digoxin. A shorter measurement may not provide a reliable assessment of the heart rate.

A. A nurse injected Demerol IM into the vastus lateralis site of adult. B. A client received gentamicin intermittent IV bolus over 1 hr. C. A client received a crushed bupropion XL tablet mixed with applesauce. D. A nurse used a 25-gauge 3/8 inch needle to administer a heparin injection.

Correct Answer is C

Explanation

C) A client received a crushed bupropion XL tablet mixed with applesauce:
Extended-release (XL) medications like bupropion XL are designed to release their active ingredients gradually over time. Crushing these tablets can alter their release mechanism, potentially leading to an overdose or reduced efficacy. This is a significant error that should be reported through an incident report to ensure patient safety and evaluate the potential impact of the mistake.

A) A nurse injected Demerol IM into the vastus lateralis site of adult:
Injecting Demerol (meperidine) intramuscularly into the vastus lateralis site is not an error. This site is commonly used for intramuscular injections in adults, though other sites like the deltoid or gluteus maximus are also appropriate depending on the situation.

B) A client received gentamicin intermittent IV bolus over 1 hr:
Gentamicin is often administered as an intermittent IV bolus over a period of time, and administering it over 1 hour is a common practice. This does not indicate an error that would require an incident report.

D) A nurse used a 25-gauge 3/8 inch needle to administer a heparin injection:
Heparin injections are typically administered with a smaller gauge needle, but a 25-gauge needle is acceptable for subcutaneous injections. The needle size might be less than ideal but does not necessarily warrant an incident report unless it directly impacts the effectiveness of the medication or causes an issue.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following actions is appropriate?

Correct Answer is B

Explanation

A nurse is reviewing the medication administration records from the previous shift. Which of the following findings should indicate to the nurse a need for an incident report?

Correct Answer is C

Explanation

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