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 ["A","C","E"]

Explanation

Choice A reason: Checking and documenting the client's vital signs is a correct action, because it provides a baseline for comparison and helps to monitor for any signs of adverse reactions to the transfusion.

Choice B reason: Ensuring that the client's IV site uses a 22-gauge needle is an incorrect action, because a larger gauge needle (18- or 20-gauge) is preferred for blood transfusions to prevent hemolysis of the RBCs.

Choice C reason: Verifying that the blood type and Rh of the packed RBCs are checked by two nurses is a correct action, because it is a standard safety procedure to prevent transfusion errors and ensure compatibility.

Choice D reason: Obtaining a bag of lactated Ringer's IV solution is an incorrect action, because only normal saline (0.9% sodium chloride) should be used as the IV solution for blood transfusions. Other solutions may cause hemolysis or clotting of the blood.

Choice E reason: Providing the RN with tubing that has a filter is a correct action, because a filter is required for blood transfusions to remove any clumps or debris from the blood.

A. Empty the drainage container every 4 hr. B. Change the client's insertion-site dressing each shift. C. Clamp the chest tube when the client is ambulating. D. Place the drainage unit below the client's chest level.

Correct Answer is D

Explanation

Choice A reason: This is an incorrect action, because emptying the drainage container every 4 hr is not necessary and can interfere with the accurate measurement of the drainage volume. The drainage container should be emptied only when it is full or at the end of the shift.

Choice B reason: This is an incorrect action, because changing the client's insertion-site dressing each shift can increase the risk of infection and dislodgment of the chest tube. The insertion-site dressing should be changed only when it is soiled or loose.

Choice C reason: This is an incorrect action, because clamping the chest tube when the client is ambulating can cause a tension pneumothorax, which is a life-threatening complication of chest tube insertion. The chest tube should be clamped only when ordered by the provider or when changing the drainage system.

Choice D reason: This is the correct action, because placing the drainage unit below the client's chest level can facilitate the drainage of air and fluid from the pleural space by gravity. The drainage unit should be kept below the client's chest level at all times.

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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

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is to receive a transfusion of packed red blood cells (RBCs). Which of the following actions should the nurse take? (Select all that apply)

Correct Answer is ["A","C","E"]

Explanation

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Correct Answer is D

Explanation

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