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?

Choice A reason: Using soap to clean the client's skin is not a recommended action, as it can dry out and irritate the skin, increasing the risk of skin breakdown and infection.

Choice B reason: Applying friction when drying the client's skin is not a recommended action, as it can damage and abrade the skin, causing pain and inflammation.

Choice C reason: Using hot water to clean the client's skin is not a recommended action, as it can increase the blood flow and inflammation to the skin, as well as remove the natural oils that protect the skin.

Choice D reason: Applying a barrier cream to the client's skin is a recommended action, as it can moisturize and protect the skin from the effects of urine, such as acidity, bacteria, and enzymes.

Choice A reason: Assessment is the first and most important phase of the nursing process, as it involves collecting and analyzing data about the patient's health status, needs, and preferences. The nurse should have assessed the patient's blood pressure before administering the antihypertensive medication, as it could have been contraindicated or required a dosage adjustment. By failing to do so, the nurse put the patient at risk of hypotension and its complications.

Choice B reason: Planning is the second phase of the nursing process, in which the nurse sets goals and outcomes for the patient's care and selects appropriate interventions. The nurse did not make an error in this phase, as the administration of the antihypertensive medication was part of the plan of care for the patient with hypertension.

Choice C reason: Diagnosis is the third phase of the nursing process, in which the nurse identifies the patient's actual or potential health problems based on the assessment data. The nurse did not make an error in this phase, as the diagnosis of hypertension was accurate and supported by the patient's history and vital signs.

Choice D reason: Evaluation is the fourth and final phase of the nursing process, in which the nurse measures the patient's progress and outcomes and modifies the plan of care as needed. The nurse did not make an error in this phase, as the re-checking of the blood pressure and the recognition of the patient's symptoms were part of the evaluation process. However, the nurse should have also notified the provider and implemented interventions to treat the hypotension.