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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Choice A rationale:
Lurasidone does not necessarily need to be taken on an empty stomach. It can be taken with or without food.
Choice B rationale:
Avoiding grapefruit juice is essential with lurasidone as it can interfere with the drug's metabolism and increase the risk of side effects.
Choice C rationale:
Changing positions slowly is relevant for medications that can cause orthostatic hypotension, but lurasidone is not typically associated with this side effect.
Choice D rationale:
Lurasidone can cause insomnia in some individuals, so it is important for the client to be aware of this potential side effect. It is best taken in the evening to minimize this effect.
Choice E rationale:
While involuntary movements (extrapyramidal symptoms) can occur with some antipsychotic medications, lurasidone has a lower risk of causing these side effects compared to older antipsychotics. It is not a major concern with lurasidone treatment.
Correct Answer is B
Explanation
Choice A rationale:
Increased peristalsis would be a positive sign and not indicative of postoperative paralytic ileus. Increased peristalsis would mean the bowel is functioning well.
Choice B rationale:
Abdominal distension is a classic sign of postoperative paralytic ileus, where the bowel's motility is reduced or absent. This condition can lead to a buildup of gas and fluids, causing the abdomen to become distended.
Choice C rationale:
Proximal high-pitched bowel sounds can be a normal finding after surgery, but they are not indicative of paralytic ileus. They may even be heard as the bowel recovers its motility.
Choice D rationale:
Passing flatus is a positive sign, as it indicates that the bowel is working and the patient is passing gas. This is not indicative of a postoperative paralytic ileus, which is characterized by the absence of bowel movement.
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