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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Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Lowering the side rail on the side of the bed where the AP will stand to perform mouth care is a safety measure. It provides better access to the client and allows the AP to perform the task more comfortably and effectively. This action helps prevent the AP from leaning over an elevated side rail, reducing the risk of injury to themselves or the client.
Choice B Reason:
Wearing clean gloves to perform mouth care for the client is a safety measure. Wearing gloves is crucial to maintain hygiene and prevent the transmission of microorganisms during mouth care.
Choice C Reason:
Using an oral care sponge swab moistened with cool water to clean the client's mouth is a safety measure. Using a moistened oral care sponge swab is a suitable method for providing mouth care to an unconscious client, helping to keep the mouth clean and moist.
Choice D Reason:
Using two gloved fingers to open the client's mouth for cleaning is NOT a safety measure. In this situation, using fingers to open the client's mouth poses a risk of injury or discomfort to the client. It's important to handle an unconscious patient's mouth with care and avoid using fingers to open the mouth forcibly.
Correct Answer is D
Explanation
Choice A Reason:
Increase in fluid requirements is incorrect. An increase in fluid requirements is more likely to contribute to changes in fluid balance and not necessarily to long-term weight gain. While short-term fluctuations in fluid retention can affect weight, sustained weight gain is not typically attributed to increased fluid intake.
Choice B Reason:
Decrease in vitamin intake is incorrect. While inadequate vitamin intake can have various health implications, direct weight gain is not a typical outcome. However, a poor diet that lacks essential nutrients, including vitamins, can lead to overall health issues, potentially influencing weight management indirectly.
Choice C Reason:
Increase in protein requirements is incorrect. An increase in protein requirements, in itself, is not likely to result in weight gain. However, a diet with an excess of calories, including proteins, can contribute to weight gain. It's essential to consider the overall dietary balance and caloric intake.
Choice D Reason:
Decrease in muscle mass is correct. Decrease in muscle mass, known as sarcopenia, is a common age-related change. As muscle mass decreases, there can be a reduction in metabolic rate, potentially leading to weight gain. Additionally, the loss of muscle may be accompanied by an increase in fat mass, contributing to changes in overall body composition.
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