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 C
Explanation
Choice A rationale:
Using fingers to remove loose tissue is not an appropriate action for the nurse to take when providing hydrotherapy for a burn wound. This action can cause further trauma to the wound and increase the risk of infection.
Choice B rationale:
Opening small blisters to expose air is contraindicated in burn wound management. The blister roof provides a natural barrier against infection, and puncturing them increases the risk of infection and delays the healing process.
Choice C rationale:
The correct answer is to wash the burn with a mild soap. Cleaning the burn wound with mild soap and water helps remove debris and minimize the risk of infection without causing additional damage.
Choice D rationale:
Applying wet-to-dry dressings is an outdated and inappropriate practice for burn wound care. Wet-to-dry dressings can be painful, disrupt wound healing, and increase the risk of infection. Modern burn wound care focuses on maintaining a moist environment to support optimal healing.
Correct Answer is D
Explanation
Choice A rationale:
Is not suitable for a client who has undergone a mastectomy with axillary lymph node dissection. This exercise may put a strain on the surgical site and cause discomfort or injury.
Choice B rationale:
Is also not appropriate for a postoperative mastectomy client. It involves using the left hand extensively, which could potentially disrupt the healing process and cause pain.
Choice C rationale:
Is not recommended for a postoperative mastectomy client. It involves significant upper body movement, which may not be well-tolerated after surgery, especially with lymph node dissection.
Choice D rationale:
This exercise is suitable for a postoperative mastectomy client as it helps in maintaining hand and arm mobility without putting excessive strain on the surgical site. It also aids in preventing complications like lymphedema, which is a potential concern after lymph node dissection.
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