The nurse should first address the client’s

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followed by the client’s

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.

Choice A rationale

Verifying the clarity and color of the eye drops is a critical safety step to ensure the medication has not been compromised. Eye drops should be clear and colorless unless specified otherwise. Any discoloration or particulate matter indicates that the solution may be contaminated or expired and should not be administered, preventing potential harm or infection to the client.

Choice B rationale

Pulling the lower lid down creates a small pocket, or conjunctival sac, which is the proper site for medication administration. This technique prevents the eye drops from immediately flowing out of the eye, allowing for maximum absorption of the medication. It also protects the cornea from direct injury by the applicator, which can be sensitive and easily scratched.

Choice C rationale

Applying gentle pressure to the punctum, the small opening in the corner of the eye, for 30 to 60 seconds after instillation prevents systemic absorption of the medication. This is particularly important for drugs like timolol, a beta-blocker, as systemic absorption can lead to adverse effects on the heart and lungs, such as bradycardia and bronchospasm.

Choice D rationale

Tilting the client's head backward facilitates proper administration by allowing gravity to assist in directing the eye drop into the conjunctival sac. This position also helps to prevent the drop from immediately rolling out of the eye or onto the client's cheek, ensuring the medication is retained in the correct location for therapeutic effect.

Choice E rationale

Administering the prescribed number of drops directly into the conjunctival sac ensures the client receives the correct dosage. The nurse should avoid touching the tip of the dropper to the client's eye or eyelashes to prevent cross-contamination of the bottle. This step is essential for both the therapeutic efficacy and safety of the medication administration. *.

Choice A rationale

The first step in inserting an indwelling urinary catheter, after gathering supplies and preparing the client, is to lubricate the tip. The application of a generous amount of water-soluble gel to the catheter tip reduces friction as it passes through the urethra. This is crucial for minimizing trauma to the urethral mucosa and decreasing client discomfort during insertion.

Choice B rationale

Positioning the sterile drape is a later step in the procedure, after the catheter has been prepared for insertion. The drape is used to create a sterile field and isolate the perineum. This helps prevent contamination of the sterile catheter and gloves from surrounding non-sterile areas, which is essential for maintaining sterility and preventing infection.

Choice C rationale

Cleansing the meatus with an antiseptic solution is a critical step, but it is performed after the catheter is lubricated and the sterile field is established. This action mechanically and chemically removes microorganisms from the perineal area, reducing the risk of introducing bacteria into the urinary tract during catheter insertion.

Choice D rationale

Attaching a prefilled syringe to the inflation hub is done after the catheter is fully inserted into the bladder and urine flow is established. This step is necessary to inflate the balloon, which secures the catheter in place and prevents it from being expelled. Doing this prematurely could cause urethral damage. *.