A client presents in the emergency room with a penetrating eye injury. The object is still present in the eye. Which nursing action is priority?
Stabilize the object
Apply anesthetic drops
Remove the object
Apply eye ointment
The Correct Answer is A
Choice A reason: This is the correct answer because stabilizing the object is the priority nursing action for a penetrating eye injury. Stabilizing the object prevents further damage to the eye structures and reduces the risk of infection and bleeding. The nurse should use a protective shield or cup to cover the eye and secure the object in place, and avoid applying any pressure or movement to the eye.
Choice B reason: This is not the correct answer because applying anesthetic drops is not the priority nursing action for a penetrating eye injury. Anesthetic drops may provide some relief from pain and discomfort, but they do not address the underlying problem of the object in the eye. Anesthetic drops should only be used under the direction of a physician, and after the object has been stabilized.
Choice C reason: This is not the correct answer because removing the object is not the priority nursing action for a penetrating eye injury. Removing the object is a surgical procedure that should only be performed by a qualified physician in a sterile environment. Attempting to remove the object by the nurse may cause more harm to the eye and increase the risk of complications.
Choice D reason: This is not the correct answer because applying eye ointment is not the priority nursing action for a penetrating eye injury. Eye ointment may interfere with the visualization and assessment of the eye, and may also contaminate the wound and cause infection. Eye ointment should only be used under the direction of a physician, and after the object has been stabilized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is not the correct answer because offering to notify the health care provider after morning rounds are completed is not the first action that the critically thinking nurse should take. The nurse should act promptly and advocate for the patient's pain management needs, rather than delaying the communication with the health care provider.
Choice B reason: This is the correct answer because exploring other options for pain relief is the first action that the critically thinking nurse should take. The nurse should assess the patient's pain level, location, quality, and contributing factors, and use a multimodal approach to pain management that includes pharmacological and non-pharmacological interventions, such as ice, heat, distraction, relaxation, or massage.
Choice C reason: This is not the correct answer because discussing the surgical procedure and reason for the pain is not the first action that the critically thinking nurse should take. The nurse should focus on alleviating the patient's pain, rather than educating the patient about the surgery. The nurse can provide information and reassurance to the patient after the pain is controlled.
Choice D reason: This is not the correct answer because explaining to the patient that nothing else has been ordered is not the first action that the critically thinking nurse should take. The nurse should not dismiss the patient's pain or imply that the patient has no other options for pain relief. The nurse should collaborate with the patient and the health care provider to find the best pain management plan for the patient.
Correct Answer is C
Explanation
Choice A reason: Cognitive domain of learning involves the mental processes of acquiring, storing, and applying knowledge. It includes skills such as remembering, understanding, analyzing, and evaluating. An example of cognitive learning is the RN asking the client to explain the purpose and effects of his inhaler.
Choice B reason: Affective domain of learning involves the emotional aspects of learning, such as attitudes, values, beliefs, and feelings. It includes skills such as receiving, responding, valuing, and committing. An example of affective learning is the RN asking the client how he feels about using his inhaler.
Choice C reason: Psychomotor domain of learning involves the physical aspects of learning, such as movement, coordination, and manipulation. It includes skills such as imitating, practicing, adapting, and creating. An example of psychomotor learning is the RN asking the client to demonstrate proper use of his inhaler.
Choice D reason: Kinesthetic domain of learning is not a recognized domain of learning, but rather a learning style that refers to the preference of learning by doing or experiencing. Kinesthetic learners tend to learn best by engaging in physical activities, such as hands-on tasks, simulations, and experiments.
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