A nurse is caring for a client who is postoperative following a left corneal transplant.

The nurse observes purulent drainage from the affected eye.

Which of the following actions is the nurse’s priority?

Apply a non-pressure patch to the affected eye.

Clean the eye from inner to outer canthus.

Notify the surgeon.

Instill an antibiotic solution in both eyes.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Applying a non-pressure patch to the affected eye can help protect the eye from further irritation or injury. However, it does not address the underlying issue of purulent drainage, which could indicate an infection that requires immediate medical attention.

Choice B rationale

Cleaning the eye from inner to outer canthus is a standard practice to prevent the spread of infection. However, in this case, the presence of purulent drainage suggests a possible infection that needs to be evaluated by a surgeon.

Choice C rationale

Notifying the surgeon is the priority action because purulent drainage from the eye can indicate a serious infection or complication following surgery. Immediate medical evaluation and intervention are necessary to prevent further complications and ensure proper treatment.

Choice D rationale

Instilling an antibiotic solution in both eyes may be part of the treatment plan for an infection. However, the nurse should first notify the surgeon to get appropriate orders and ensure that the correct antibiotic and treatment plan are followed.

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Correct Answer is C

Explanation

Choice A rationale

Informing the client that she will need to bring the tick for testing is not necessary. While having the tick can help identify the species and potential risk, it is not required for testing for Lyme disease. The diagnosis can be made based on clinical symptoms and blood tests.

Choice B rationale

Informing the client that the tick is needed to perform a test is incorrect. The presence of the tick is not required for testing for Lyme disease. Blood tests can detect antibodies to the bacteria that cause Lyme disease, even if the tick is not available.

Choice C rationale

Referring the client for a blood test immediately is the appropriate action. Early testing can help diagnose Lyme disease and initiate treatment promptly. Blood tests can detect antibodies to Borrelia burgdorferi, the bacteria that cause Lyme disease, and help confirm the diagnosis.

Choice D rationale

Asking the client about the size and color of the tick is not the most appropriate action. While this information can provide some context, it does not directly contribute to the diagnosis of Lyme disease. The priority is to refer the client for a blood test to confirm the presence of the infection.

A. Electrical cords are placed along the walls. B. Scatter rugs are present in the kitchen. C. Handrails are present in the bathroom. D. Uses a microwave for cooking.

Correct Answer is B

Explanation

Choice A rationale

Electrical cords placed along the walls are generally not a safety risk as long as they are secured and not in the walking path. This placement can actually reduce tripping hazards.

Choice B rationale

Scatter rugs are a significant safety risk for older adults with decreased vision. They can easily cause tripping and falls, which can lead to serious injuries.

Choice C rationale

Handrails in the bathroom are a safety feature that helps prevent falls and provides support for individuals with decreased vision or mobility issues.

Choice D rationale

Using a microwave for cooking is generally safe for older adults with decreased vision as it reduces the risk of burns and accidents associated with stovetop cooking.

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A nurse is caring for a client who is postoperative following a left corneal transplant. The nurse observes purulent drainage from the affected eye. Which of the following actions is the nurse’s priority?

Nursing Test Bank

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A nurse is caring for a client who is postoperative following a left corneal transplant.

The nurse observes purulent drainage from the affected eye.

Which of the following actions is the nurse’s priority?