Nokea
The client comes to the emergency department after splashing chemicals into the eyes. Which intervention should the nurse implement first?
- A. Have the client move the eyes in all directions.
- B. Administer a broad-spectrum antibiotic.
- C. Irrigate the eyes with normal saline solution.
- D. Determine when the client had a tetanus shot.
Correct Answer: C
Rationale: Immediate irrigation with normal saline removes chemicals, preventing corneal damage. Eye movement, antibiotics, and tetanus history are secondary.
You may also like to solve these questions
The female client tells the clinic nurse she is going on a seven (7)-day cruise and is worried about getting motion sickness. Which information should the nurse discuss with the client?
- A. Make an appointment for the client to see the health-care provider.
- B. Recommend getting an over-the-counter scopolamine patch.
- C. Discourage the client from taking the trip because she is worried.
- D. Instruct the client to lie down and the motion sickness will go away.
Correct Answer: B
Rationale: A scopolamine patch prevents motion sickness effectively. HCP appointments, trip discouragement, and lying down are less practical.
The nurse is reviewing the new nurse's discharge instructions for the client following outpatient cataract surgery. Which statement should the nurse remove from the discharge instructions?
- A. Avoid lifting, pushing, or pulling objects heavier than 15 pounds.
- B. Clean the eye with a clean tissue; wipe from inner to outer eye.
- C. Cough and deep breathe every 2 to 3 hours while you are awake.
- D. Avoid lying on the side of the affected eye the night after surgery.
Correct Answer: C
Rationale: The client should not cough because this will increase the pressure within the eye and risk for complications. Lifting heavy objects increases pressure on the surgical eye. The surgical eye should be cleaned with a clean tissue from the inner to outer canthus to prevent obstruction of the ducts with drainage. Lying on the side of the surgical eye can increase pressure on the surgical eye.
Which assessment technique should the nurse implement when assessing the client's cranial nerves for vibration?
- A. Move the big toe up and down and ask in which direction the vibration is felt.
- B. Place a tuning fork on the big toe and ask if the vibrations are felt.
- C. Tap the client's cheek with the finger and determine if vibrations are felt.
- D. Touch the arm with two sharp objects and ask if one (1) vibration or two (2) is felt.
Correct Answer: B
Rationale: Placing a tuning fork on the big toe assesses vibration sense (via dorsal column pathways), not cranial nerves directly, but is the correct technique. Other options assess different sensations.
A 50-year-old client is admitted with the diagnosis of open-angle glaucoma. Which of the following symptoms would the nurse expect the client to have?
- A. Severe eye pain
- B. Constant blurred vision
- C. Severe headaches, nausea, and vomiting
- D. Reports of seeing halos around objects
Correct Answer: D
Rationale: Open-angle glaucoma is characterized by halos around objects due to increased intraocular pressure, not severe pain or headaches.
The nurse is caring for multiple older adult clients with age-related visual changes. Which intervention should the nurse implement?
- A. Provide reading materials with boldface, normal-sized font.
- B. Lower the intensity of reading lamps to prevent glare.
- C. Provide the clients with a magnifying device for reading.
- D. Give clients printed materials that use similar, blended colors.
Correct Answer: C
Rationale: The nurse should provide a magnifying device for reading to enlarge words, making them easier to read. Normal-sized fonts, low-intensity lamps, and blended colors are less effective for visual changes.