A nurse in the emergency department is preparing to irrigate the eyes of a client who received a chemical splash on their face. Which of the following actions should the nurse take?

Completely irrigate one eye before irrigating the second eye.

Inform the client they will need to blink their eyes rapidly during the irrigation process.

Delay the irrigation process until the type of chemical in the eyes is identified.

Ask the client to count the number of fingers held up by the nurse prior to irrigating their eyes.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Completely irrigating one eye before irrigating the second eye is the correct action to take when a client receives a chemical splash on their face. This approach helps prevent the potential spread of the chemical from one eye to the other. Irrigation should be done immediately to flush out the chemical and minimize its harmful effects.

Choice B rationale:

Informing the client to blink their eyes rapidly during the irrigation process is not recommended. Blinking may exacerbate the dispersion of the chemical and could lead to further damage to the eyes. Instead, the client should keep their eyes open during irrigation.

Choice C rationale:

Delaying the irrigation process until the type of chemical in the eyes is identified is not appropriate. Time is critical in minimizing the impact of the chemical on the eyes. Immediate irrigation is essential, regardless of the type of chemical, to remove the substance from the eyes.

Choice D rationale:

Asking the client to count the number of fingers held up by the nurse before irrigating their eyes is not relevant in this situation. The priority is to initiate immediate irrigation to remove the chemical from the eyes. Assessing the client's visual acuity can be done later in the evaluation process after the eyes have been irrigated.

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Correct Answer is C

Explanation

Choice A rationale:

Preparing an endotracheal tube for intubation is not the first action the nurse should take in this situation. Intubation is an invasive procedure and should be reserved for cases where other, less invasive methods of airway management have failed.

Choice B rationale:

Inserting a plastic oral airway may help maintain the airway in some situations, but it is not the first action to take when the client's airway is obstructing and their oxygen saturation is low.

Choice C rationale:

Providing oxygen using a manual resuscitation bag (bag-valve-mask device) is the correct first action. This allows the nurse to manually assist the client's breathing and deliver oxygen more effectively than just providing supplemental oxygen through a nasal cannula or face mask.

Choice D rationale:

Performing a head tilt with a chin-lift is a basic airway maneuver, but it may not be sufficient in this situation, especially if the airway is completely obstructed. Providing oxygen with a manual resuscitation bag takes precedence.

A. "Administer this medication into your leg muscle.". B. "Expel the excess air in the syringe before you administer the medication.". C. "Insert the entire needle into your skin to administer medication completely.". D. "Take ibuprofen for fever following administration of this medication.".

Correct Answer is C

Explanation

Answer: C. "Insert the entire needle into your skin to administer medication completely."

Rationale:

A) "Administer this medication into your leg muscle."
Enoxaparin should be administered subcutaneously, typically in the abdominal area, not into a muscle. Injecting it intramuscularly can lead to unpredictable absorption and increase the risk of bleeding.

B) "Expel the excess air in the syringe before you administer the medication."
This statement is incorrect. For enoxaparin, it is recommended to retain the air bubble in the syringe. The air bubble helps ensure the entire dose is delivered and minimizes leakage at the injection site.

C) "Insert the entire needle into your skin to administer medication completely."
This is an appropriate instruction as it emphasizes the need to fully insert the needle for effective subcutaneous delivery of enoxaparin. Proper technique is essential to ensure the medication is administered as intended.

D) "Take ibuprofen for fever following administration of this medication."
This recommendation is not advisable because ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), can increase the risk of bleeding, especially when taken concurrently with enoxaparin. The client should consult their healthcare provider for safe alternatives for managing fever or pain.

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A nurse in the emergency department is preparing to irrigate the eyes of a client who received a chemical splash on their face. Which of the following actions should the nurse take?

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