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 min is inappropriate. Turning off the hearing aid may not address the underlying issue of feedback. Adjusting the volume or checking for proper placement is more appropriate.
Choice B Reason:
Cleaning the hearing aid with isopropyl alcohol is inappropriate. While cleaning the hearing aid is important for maintenance, using isopropyl alcohol may damage certain components. It's generally recommended to use a specialized cleaning solution recommended by the hearing aid manufacturer.
Choice C Reason:
Decreasing the volume on the hearing aid is appropriate. The whistling sound, also known as feedback, can occur when the volume is set too high. Lowering the volume should help alleviate the feedback and improve the client's experience with the hearing aid.
D. Soak the hearing aid in warm water.
Soaking a hearing aid in water is not recommended, as it can damage the electronic components. Hearing aids are sensitive to moisture, and water exposure can lead to malfunction.
Correct Answer is A
Explanation
Choice A Reason:
"I should advance my crutches up the step ahead of my unaffected leg." This statement demonstrates correct technique for ascending stairs with crutches. When going up stairs, the client should advance the crutches onto the step first, followed by the unaffected leg.
Choice B Reason:
"I should keep my elbows straight when I am walking with my crutches." The client should maintain a slight bend in the elbows while walking with crutches to provide stability and support.
Choice C Reason:
"I will support my weight on the hand grips of the crutches." The client should not support their weight on the hand grips alone; weight should be distributed through the hands and arms to avoid putting excessive pressure on the axillae.
Choice D Reason:
"When I'm walking around my house with my crutches, it's okay to take my shoes off." It is generally not advisable to walk with crutches without shoes, as wearing shoes provides better support and stability. The client should wear supportive, non-skid footwear while using crutches.
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