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

Tilt the client's head away from the side receiving the drops.

Instill the drops directly onto the cornea of the eye receiving the drops.

Rest the dominant hand on the client's forehead while instilling the drops.

Hold the medication dropper 0.5 cm (0.2 in) above the conjunctival sac.

Answer and Explanation

The Correct Answer is C

A. Tilt the client's head away from the side receiving the drops: The client’s head should be tilted slightly back and toward the side receiving the drops, not away. Tilting away may cause the medication to run out instead of entering the conjunctival sac.

B. Instill the drops directly onto the cornea of the eye receiving the drops: The cornea is highly sensitive, and placing drops directly on it can cause pain, reflex blinking, or injury. Drops should be placed into the conjunctival sac to ensure comfort and proper absorption.

C. Rest the dominant hand on the client's forehead while instilling the drops: Resting the hand on the forehead stabilizes the dropper, preventing accidental injury if the client moves suddenly. This provides safety and accuracy when administering the medication.

D. Hold the medication dropper 0.5 cm (0.2 in) above the conjunctival sac: The dropper should be held about 1–2 cm above the sac to avoid touching the eye. Holding it too close increases the risk of contamination or accidental contact with the eye surface.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. A client who has chronic back pain and a history of physical maltreatment: Therapeutic touch involves close physical proximity and intentional hand movements, which may trigger psychological distress or trauma responses in individuals with a history of maltreatment.

B. A client who has chronic joint discomfort and a history of mild dementia: Clients with mild dementia may still tolerate therapeutic touch well, as it can provide comfort and reduce agitation. With careful explanation and reassurance, this intervention can be beneficial.

C. A client who has chronic knee pain and a history of grand mal seizures: Therapeutic touch does not induce seizures, as it is a noninvasive energy-based practice. It does not increase seizure risk in clients with a seizure history.

D. A client who has chronic hip pain and a history of uterine cancer: Having a history of cancer is not a contraindication to therapeutic touch. This approach does not involve deep tissue manipulation and can be safely applied to provide comfort and pain relief.

A. Client's present condition B. Questions for the provider regarding client care C. Physical findings D. Previous treatments

Correct Answer is D

Explanation

A. Client's present condition: The present condition is part of the “situation” portion of SBAR, describing why the nurse is contacting the provider. It is not included in the background section.

B. Questions for the provider regarding client care: Questions or recommendations are included in the “recommendation” portion of SBAR, not the background. They indicate what the nurse is requesting or suggesting for the client’s care.

C. Physical findings: Physical assessment data are reported in the “assessment” section of SBAR, providing objective information about the client’s current status rather than historical context.

D. Previous treatments: Previous treatments, medical history, and relevant background information are included in the “background” section. This information gives the provider context about the client’s condition and prior interventions.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is planning to use therapeutic touch for a group of selected clients who have chronic pain. The nurse should identify that the use of therapeutic touch is contraindicated for which of the following clients?

Correct Answer is A

Explanation

A nurse is preparing to notify the provider about a change in a client's status. Which of the following information should the nurse plan to include in the "background" portion of the Situation, Background, Assessment, Recommendation (SBAR) communication tool?

Correct Answer is D

Explanation

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