A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye.
Which of the following actions should the nurse plan to take first?
Place a strip of pH paper onto the cul-de-sac of the affected eye.
Administer proparacaine eye drops into the affected eye.
Install 0.9% sodium chloride solution into the affected eye.
Collect information about the irritant that caused the injury.
The Correct Answer is D
The first action the nurse should take is to collect information about the irritant that caused the injury.
This information is important because it can help determine the appropriate treatment and irrigation solution to use.
Choice A is incorrect because airborne precautions are used to prevent the spread of infectious diseases that are transmitted through the air, and are not necessary in this situation.
Choice B is incorrect because administering proparacaine eye drops into the affected eye is not the first action the nurse should take.
Proparacaine is a topical anesthetic that can be used to numb the eye before performing ocular irrigation, but it is not the first action the nurse should take.
Choice C is incorrect because installing 0.9% sodium chloride solution into the affected eye is not the first action the nurse should take; the nurse should first collect information about the irritant that caused the injury before performing ocular irrigation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
If the new TPN solution is not available, the nurse should infuse dextrose 10% in water to prevent hypoglycemia.
Choice A is incorrect because disconnecting and flushing the IV access line would interrupt the client’s nutrition and could lead to hypoglycemia.
Choice B is incorrect because lactated Ringer’s solution does not provide the necessary glucose to prevent hypoglycemia.
Choice C is incorrect because decreasing the TPN infusion rate would not provide the necessary glucose to prevent hypoglycemia.
Correct Answer is C
Explanation
The nurse’s priority for immediate intervention is tachypnea, which is rapid breathing.
Tachypnea can be a sign of respiratory distress and requires immediate intervention.
Choice A is wrong because while a fever may indicate an infection, it is not the priority for immediate intervention.
Choice B is wrong because while blood-tinged secretions may indicate bleeding, it is not the priority for immediate intervention.
Choice D is wrong because while IV infiltration may cause discomfort and require attention, it is not the priority for immediate intervention.
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