A nurse is performing eye care for a client who is in a coma. Which of the following actions should the nurse take? (Select all that apply.)
Wipe the eyes from the outer to the inner canthus.
Apply eye patches over the eyes if the eyelids do not close completely.
Cleanse the eyes with a chlorhexidine solution.
Place moist compresses over the eyes every 2 to 4 hr.
Instill lubricating eye drops into the lower lid of each eye.
Correct Answer : B,D,E
Choice A Reason:
Wiping the eyes from the outer to the inner canthus is inappropriate. This direction of wiping might risk introducing contaminants into the eyes. It's generally advised to wipe from the inner to the outer canthus to minimize the risk of introducing potential eye irritants.
Choice B Reason:
Applying eye patches over the eyes if the eyelids do not close completely is appropriate. Eye patches help protect the eyes from potential damage, dryness, or exposure to light if the eyelids do not close fully.
Choice C Reason:
Cleansing the eyes with a chlorhexidine solution is inappropriate. Chlorhexidine solution might be too harsh for use around the delicate eye area and could cause irritation or damage to the eyes. Using a gentler and specifically formulated eye cleansing solution or sterile saline is usually recommended for eye care.
Choice D Reason:
Placing moist compresses over the eyes every 2 to 4 hours is appropriate. Moist compresses can help maintain moisture and prevent dryness in the eyes, reducing the risk of corneal damage due to the inability to blink.
Choice E Reason:
Instilling lubricating eye drops into the lower lid of each eye is appropriate. Lubricating eye drops help prevent dryness and maintain eye moisture, offering protection to the cornea.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Turning the hearing aid off for 5 minutes is inappropriate action. Turning the hearing aid off may temporarily stop the whistling sound, but it doesn't address the underlying issue. Additionally, it would leave the client without the ability to hear during that time.
Choice B Reason:
Cleaning the hearing aid with isopropyl alcohol is inappropriate action. While cleaning the hearing aid is important for maintenance, using isopropyl alcohol may not directly address the issue of whistling. It's a good practice for routine cleaning, but it may not be the solution in this specific case.
Choice C Reason:
Decreasing the volume on the hearing aid is appropriate action. Whistling sounds, also known as feedback, can occur when the volume on the hearing aid is too high. Decreasing the volume is a reasonable first step to address this issue.
Choice D Reason:
Soaking the hearing aid in warm water is inappropriate. Soaking a hearing aid in warm water is not recommended, as moisture can damage the internal components of the hearing aid. It's essential to keep hearing aids dry to ensure proper functioning.
Correct Answer is A
Explanation
Choice A Reason:
Pressing on the skin barrier for about 30 seconds ensures that it adheres properly to the skin, which helps secure the ostomy appliance and prevents leakage.
Choice B Reason:
Moisturizing soap is not recommended for cleaning around the stoma, as it can leave a residue that interferes with the appliance's adhesion. Mild soap without moisturizers or just water should be used.
Choice C Reason:
Applying talc powder around the stoma can prevent the appliance from adhering properly, leading to leakage. It is not recommended for ostomy care.
Choice D Reason:
The skin barrier should be cut to fit closely around the stoma, leaving no more than a 1/8 inch gap, not 1/2 inch. A larger opening may cause skin irritation or leakage.
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