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 C
Explanation
A hypertensive crisis is an emergent situation in which a marked elevation in diastolic blood pressure can cause end-organ damage.
The nurse should perform neurological assessments to monitor for any changes in the patient’s level of consciousness and other neurological symptoms.
Choice A is incorrect because dopamine is not typically used to treat hypertensive crises.
Choice B is incorrect because lactated Ringer’s solution is not typically used to treat hypertensive crises.
Choice D is incorrect because placing the client supine may not be appropriate and could potentially worsen their condition.
Correct Answer is C
Explanation
Prealbumin is a protein that is produced by the liver and is used as a marker of nutritional status.
It has a short half-life, so changes in pre albumin levels can reflect recent changes in nutritional status.
Monitoring pre albumin levels can help assess the effectiveness of total parenteral nutrition.
Lipase is an enzyme that is produced by the pancreas and is not used to monitor overall nutritional status.
B) C-reactive protein is a marker of inflammation and is not used to monitor overall nutritional status.
D) Creatinine is a waste product that is produced by muscle metabolism and is not used to monitor overall nutritional status.
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