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 this statement by the client indicates that the client understands the dietary restrictions and guidelines that are necessary after bariatric surgery. A liquid/pureed diet and limited fluid intake are recommended to prevent complications such as nausea, vomiting, dehydration, and dumping syndrome.
Choice B reason: This is the correct answer because this statement by the client indicates that the client does not understand the importance of a thorough evaluation by the surgeon prior to the procedure. Bariatric surgery is a major surgery that involves significant risks and benefits, and requires careful consideration of the client's medical history, physical condition, psychological status, and readiness for lifestyle changes. The surgeon should assess the client's eligibility, suitability, and expectations for the surgery, and provide informed consent and education.
Choice C reason: This is not the correct answer because this statement by the client indicates that the client understands the basic principles and types of bariatric surgery. Bariatric surgery can be classified into restrictive, malabsorptive, or combined procedures, depending on how they affect the size of the stomach and the absorption of food. The most common types of bariatric surgery are gastric bypass, sleeve gastrectomy, and adjustable gastric banding.
Choice D reason: This is not the correct answer because this statement by the client indicates that the client understands the long-term implications and commitments of bariatric surgery. Bariatric surgery is not a quick fix or a magic solution for obesity, but rather a tool that helps the client achieve and maintain weight loss and improve health outcomes. The client should be aware that bariatric surgery requires lifelong changes in diet, exercise, medication, supplementation, and follow-up care.
Correct Answer is D
Explanation
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.
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