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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
A. Peer pressure: Peer pressure is considered an external stressor because it originates from outside influences, such as social interactions and the expectations of others. It impacts behavior but is not generated internally.
B. Death of a family member: The loss of a loved one is an external stressor since it arises from an environmental and situational event outside the individual’s control. The stress reaction follows the external occurrence.
C. Fear of medical test results: Fear is an internal stressor because it originates from the individual’s own thoughts, emotions, and perceptions. It reflects how the person interprets and responds to a situation, even before external outcomes are known.
D. Job transfer to another city: A job transfer is an external stressor because it is an environmental change imposed on the individual. The stress arises from circumstances in the person’s surroundings rather than internal feelings.
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