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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A Reason:

"Call me so that I can help you change your position." This response offers practical assistance and comfort to the client. Repositioning can sometimes alleviate discomfort associated with breathing difficulties, and the nurse can offer guidance or physical help to adjust the client's position for improved comfort.

Choice B Reason:

"Try to close your eyes and get some sleep." This response doesn't directly address the client's immediate concern about difficulty breathing and may not offer practical help.

Choice C Reason:

"It is common for breathing to become more difficult as time goes on." While this statement acknowledges the situation, it might not provide the client with actionable guidance or support on how to manage the difficulty in breathing.

Choice D Reason:

"Therapy choices are limited for clients who do not want resuscitation." This response might be interpreted as dismissive or unrelated to the client's immediate needs, focusing more on the DNR order rather than addressing the current concern about breathing difficulties.

A. Discontinue supplements containing vitamin C 24 hr before the test. B. Place a thick layer of stool on the specimen card. C. Urinate prior to collecting the stool specimen. D. Refrain from consuming pork 7 days before the test.

Correct Answer is C

Explanation

Choice A Reason:

Discontinuing supplements containing vitamin C 24 hr before the test is appropriate. This is not necessary for fecal occult blood testing. However, vitamin C supplements should be avoided before certain stool tests that use a chemical reaction involving guaiac.

Choice B Reason:

Placing a thick layer of stool on the specimen card is inappropriate. The client should apply a small amount of stool to the designated area on the specimen card. A thick layer is not required, and excess stool may interfere with the test.

Choice C Reason:

Urinating prior to collecting the stool specimen is appropriate. This instruction is important because it helps prevent contamination of the stool specimen with urine, which could potentially interfere with the accuracy of the test results.

Choice D Reason:

Refraining from consuming pork 7 days before the test is inappropriate. There is no need for the client to avoid consuming pork specifically for fecal occult blood testing. The instructions usually focus on dietary restrictions that could affect the presence of blood in the stool, such as avoiding red meat or certain medications.

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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.)

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is terminally ill and has a do-not-resuscitate order on his medical record. The client asks, "What should I do if I have difficulty breathing?" Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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