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 A
Explanation
Choice A reason: Gradual loss of peripheral vision is a characteristic symptom of open-angle glaucoma, which is the most common type of glaucoma. It occurs when the drainage angle of the eye becomes blocked, causing increased intraocular pressure and damage to the optic nerve.
Choice B reason: Gradual loss of central vision is more typical of age-related macular degeneration, which is a condition that affects the macula, the central part of the retina. It is not a symptom of open-angle glaucoma.
Choice C reason: Sudden headache and nausea are signs of acute angle-closure glaucoma, which is a medical emergency that requires immediate treatment. It occurs when the drainage angle of the eye suddenly closes, causing a rapid rise in intraocular pressure and severe pain.
Choice D reason: Cloudy blurred vision is a symptom of cataract, which is a condition that causes the lens of the eye to become cloudy and opaque. It is not a symptom of open-angle glaucoma.
Correct Answer is D
Explanation
Choice A reason: Nurses can accomplish more if they perform the easiest or fastest interventions is not a primary reason for prioritizing care. This statement implies that nurses should focus on the quantity rather than the quality of care. However, nurses should prioritize care based on the urgency and complexity of the patient's needs, not on the ease or speed of the interventions. Performing the easiest or fastest interventions may not address the most important or critical issues that the patient faces.
Choice B reason: Nurses should always perform interventions related to client preference early in the shift is not a primary reason for prioritizing care. This statement implies that nurses should base their care on the patient's wishes rather than the patient's condition. However, nurses should prioritize care based on the severity and acuity of the patient's problems, not on the patient's preference. Performing interventions related to client preference early in the shift may not be feasible or appropriate if the patient has more urgent or emergent needs that require immediate attention.
Choice C reason: Nurses need to plan how to accomplish all activities within one shift is not a primary reason for prioritizing care. This statement implies that nurses should focus on the completion rather than the quality of care. However, nurses should prioritize care based on the significance and impact of the patient's outcomes, not on the completion of the activities. Accomplishing all activities within one shift may not be possible or necessary if the patient's situation changes or if some activities can be delegated or postponed.
Choice D reason: Nurses have a limited amount of time to perform nursing interventions during a shift is a primary reason for prioritizing care. This statement acknowledges that nurses face time constraints and competing demands in their work environment. Therefore, nurses should prioritize care based on the best use of their time and resources to meet the patient's needs. Having a limited amount of time to perform nursing interventions during a shift requires nurses to make clinical judgments and decisions that optimize the patient's health and safety.
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