Nokea
Which of the following would be the most appropriate action for the nurse to take when applying eye patches to the client?
- A. Occluding all sources of room light
- B. Ensuring that both patches exert tight pressure on the eyes
- C. Maintaining the client's eyelids in a closed position
- D. Making sure the client can see while the patches are in place
Correct Answer: C
Rationale: Keeping eyelids closed under patches prevents movement and further retinal damage.
You may also like to solve these questions
The nurse is caring for the client with the pressure ulcer illustrated. Which stage should the nurse document?
- A. Stage I pressure ulcer
- B. Stage II pressure ulcer
- C. Stage III pressure ulcer
- D. Stage IV pressure ulcer
Correct Answer: C
Rationale: Stage III pressure ulcer is full-thickness skin loss that extends to the subcutaneous fat, but not fascia; bone, tendon, and muscle are not visible. Stage I is intact but red and nonblanching. Stage II involves a break in the skin with partial-thickness loss. Stage IV is full-thickness loss with exposed muscle and bone.
The nurse administered morphine sulfate, a narcotic analgesic, IVP 45 minutes ago to a client diagnosed with herpes zoster. On reassessment, the client complains the pain decreased to a '5' on a 1-to-10 scale. Which intervention should the nurse implement?
- A. Turn on soft music and shut the blinds.
- B. Apply warm, moist heat to the lesions.
- C. Notify the HCP for more pain medication.
- D. Encourage the client to ambulate with assistance.
Correct Answer: A
Rationale: Soft music and dim lighting provide nonpharmacologic pain relief for herpes zoster. Heat may worsen pain, more medication is premature, and ambulation is unrelated.
After cataract surgery, the client tells the nurse of severe pain in the operative eye. Which nursing action is most appropriate?
- A. Report the finding to the charge nurse.
- B. Give the client a prescribed analgesic.
- C. Assess the client's pupil response with a penlight.
- D. Reposition the client on the operative side.
Correct Answer: A
Rationale: Severe pain may indicate complications, requiring immediate reporting to the charge nurse.
Which expected outcome should the nurse include in the plan of care for the client diagnosed with seborrheic dermatitis?
- A. The client will have no further outbreaks.
- B. The client will follow medical protocol.
- C. The client will shampoo three (3) times a week.
- D. The client will apply bacitracin twice daily.
Correct Answer: B
Rationale: Following medical protocol ensures effective management of seborrheic dermatitis. No outbreaks is unrealistic, shampoo frequency varies, and bacitracin is for bacterial infections.
When irrigating the client's eyes, which technique describes the best way to direct the flow of irrigating solution?
- A. Directly onto the corneal surface
- B. Away from the inner canthus
- C. Within the anterior chamber
- D. Toward the nasolacrimal duct
Correct Answer: B
Rationale: Directing the flow away from the inner canthus (from outer to inner) prevents contamination of the unaffected eye.