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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: This is an incorrect instruction, because the client does not need to remain NPO, or nothing by mouth, before a standard EEG. The client can eat and drink normally, unless the provider instructs otherwise.

Choice B reason: This is an incorrect instruction, because the client should not take a sedative, or any other medication that can affect the brain activity, before a standard EEG. The client should take the usual medications, unless the provider instructs otherwise.

Choice C reason: This is the correct instruction, because the client should thoroughly shampoo hair prior to the EEG. The client should wash the hair with a mild shampoo and rinse well, without using any conditioner, gel, spray, or other hair products. This can help remove any oil, dirt, or residue that can interfere with the placement and function of the electrodes.

Choice D reason: This is an incorrect instruction, because the client should not take an additional dose of anticonvulsant medication before a standard EEG. The client should take the regular dose of anticonvulsant medication, unless the provider instructs otherwise.

A. “I should check my heart rate each day.” B. “I don't have to take my antihypertensive medications now that I have a pacemaker.” C. “I should stretch my arms above my head every 4 hr.” D. “I cannot stand in front of our new microwave oven when it's on.”

Correct Answer is A

Explanation

Choice A reason: This is a correct statement, because checking the heart rate each day can help monitor the function and effectiveness of the pacemaker, and detect any signs of malfunction, such as bradycardia, tachycardia, or irregular rhythm.

Choice B reason: This is an incorrect statement, because the client still needs to take the antihypertensive medications as prescribed, even with a pacemaker. The pacemaker regulates the heart rate, but does not control the blood pressure, which can be affected by other factors, such as stress, diet, or kidney function.

Choice C reason: This is an incorrect statement, because the client should avoid stretching the arms above the head for the first few weeks after the pacemaker insertion, as it can cause dislodgment or damage to the pacemaker leads. The client should limit the arm movements and activities until the incision site heals and the provider approves.

Choice D reason: This is an incorrect statement, because the client can stand in front of a microwave oven without any risk, as long as the oven is in good working condition and does not leak radiation. The modern microwave ovens and pacemakers are designed to prevent any interference or damage. However, the client should avoid close contact with other sources of electromagnetic fields, such as metal detectors, cell phones, or MRI machines.

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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?

Nursing Test Bank

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