The nurse is caring for an immobile client and identifies these findings: Painful,
persistent non-blanchable erythema at site of right greater trochanter. Skin remains intact. How would the nurse identify these findings in documentation?

A. Ask the client to look downward during the instillation: Proper technique requires the client to look upward toward the ceiling during the procedure. This posture moves the cornea away from the lower lid and reduces the risk of accidental trauma to the sensitive corneal tissue. It also facilitates easier access to the lower conjunctival sac for drop placement.

B. Wear sterile gloves prior to opening the eye drop container: Standard precautions for ophthalmic medication administration typically require clean, non-sterile gloves rather than sterile ones. The most critical factor is maintaining the sterility of the dropper tip by ensuring it does not contact any ocular or cutaneous surfaces. Clean gloves protect the nurse from contact with secretions.

C. Administer the number of drops ordered into the conjunctival sacs: The lower conjunctival sac provides a physiological reservoir that can safely hold the medicated fluid. Placing drops directly onto the cornea is painful and may cause damage to the epithelial layer. This method ensures systemic absorption via the mucous membranes while minimizing the blink reflex.

D. Cleanse the client's eyelids from the outer canthus to the inner canthus: Eyelids should always be cleansed from the inner canthus to the outer canthus. Moving from the nose outward prevents the introduction of environmental debris or pathogens into the lacrimal duct and the eye itself. This unidirectional motion maintains optimal ocular hygiene and prevents cross-contamination.

A. That much ibuprofen should relieve your pain: This response is dismissive of the client's subjective experience of pain and fails to address safety. Pain threshold and intensity vary among individuals regardless of standard dosing. It lacks the necessary education regarding the maximum daily limits of the medication.

B. You probably should ask your healthcare provider if it is acceptable: While referring to a provider is necessary, this response is too passive and misses an immediate teaching opportunity. The nurse must identify the specific safety risk associated with the current dosage. It does not provide the rationale for the referral.

C. That amount is greater than the recommended daily amount. Discussing your increased pain with your healthcare provider is important: Doubling 400 mg every 4 hours results in 4800 mg daily, exceeding the 3200 mg maximum safe limit. This creates a high risk for gastrointestinal erosion and renal toxicity. The nurse must prioritize patient safety through education and provider consultation.

D. Ibuprofen is eliminated by the kidneys. It would be important for your healthcare provider to order BUN and creatinine levels to determine if the increased dose is safe: This focuses on diagnostic monitoring rather than the immediate danger of exceeding the maximum daily dose. While renal function is relevant, the priority is preventing toxicity by correcting the dosage. Staging the response around lab tests delays the necessary intervention.