A nurse in a provider's office is caring for a client who has blepharitis. Which of the following actions should the nurse take first?
Reinforce teaching with the client about proper instillation of antibiotic eye drops.
Apply warm compresses to the affected eye.
Dim the lights in the client examination room.
Inspect the eyes for drainage or redness.
The Correct Answer is D
Choice A reason: This is an important action, but not the first one. The nurse should first address the client's comfort and inflammation before teaching them how to use the eye drops.
Choice B reason: Option B (warm compresses) is a key intervention for blepharitis to improve meibomian gland function and reduce crusting. However, assessment (Option D) must precede treatment to ensure no contraindications (e.g., corneal abrasion) and tailor care appropriately.
Choice C reason: This is a helpful action, but not the first one. The nurse should first apply warm compresses to the affected eye, and then dim the lights to reduce the sensitivity and pain.
Choice D reason: The first step in the nursing process is assessment. Even with a diagnosis of blepharitis, the nurse must inspect the eyes to evaluate the current severity, presence of drainage (e.g., purulent vs. serous), redness, or signs of secondary infection (e.g., bacterial involvement). This informs subsequent interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
The correct answer is A, C, D
Choice A reason: Allopurinol is a medication that helps reduce the production of uric acid, which is beneficial for patients with gout and urolithiasis to prevent the formation of uric acid stones.
Choice B reason: While regular exercise is generally beneficial for overall health, it does not have a direct impact on the prevention of uric acid stone formation. Therefore, it is not a specific recommendation for preventing uric acid stone.
Choice C reason: Foods high in purines can increase uric acid levels in the body, leading to the formation of uric acid stones. Limiting the intake of such foods is a key step in preventing uric acid stones.
Choice D reason: Adequate fluid intake is crucial as it helps to dilute the urine, which can prevent the formation of uric acid stones by reducing the concentration of uric acid in the urine.
Choice E reason: Contrary to the statement, lemonade may actually be beneficial in preventing uric acid stones because it contains citrate, which can help prevent stone formation. Citrate can bind to calcium and prevent stone formation, and it also makes the urine less acidic, which can help prevent the formation of uric acid stones.
Correct Answer is B
Explanation
Choice A reason: This is an important action, but not the first one. The nurse should obtain sample menus from the dietitian to give to the client after assessing the client's food preferences, needs, and goals. The sample menus should be individualized and tailored to the client's lifestyle, culture, and preferences.
Choice B reason: This is the first action, because the nurse should ask the client to identify the types of foods she prefers before providing any dietary teaching. This can help the nurse to determine the client's current eating habits, knowledge, and readiness to learn. It can also help the nurse to establish rapport and trust with the client, and to involve the client in the decision-making process.
Choice C reason: This is an important action, but not the first one. The nurse should identify the recommended range for the client's blood glucose level after assessing the client's food preferences, needs, and goals. The recommended range for the blood glucose level depends on the type, dose, and timing of the medication, the frequency and intensity of the exercise, and the carbohydrate intake of the client.
Choice D reason: This is an important action, but not the first one. The nurse should discuss long-term complications that can result from nonadherence to the dietary plan after assessing the client's food preferences, needs, and goals. The long-term complications of diabetes mellitus include cardiovascular disease, kidney disease, nerve damage, eye damage, and foot problems. The nurse should explain the benefits of following the dietary plan and the risks of not following it.
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