The emergency department nurse is caring for a patient who has had a chemical splash in both eyes. What is the priority nursing action?

Instill anesthetic eye drops in both eyes

Perform a visual acuity exam

Determine the pH of the chemical splash

Irrigate both eyes with normal saline

Answer and Explanation

The Correct Answer is D

A. Anesthetic eye drops can help with pain, but irrigation is the priority to prevent further damage.

B. A visual acuity exam is part of the assessment but should be performed after initial irrigation to prevent further damage.

C. Determining the pH of the chemical splash can guide further treatment but is secondary to immediate irrigation to dilute and remove the chemical.

D. Irrigating both eyes with normal saline is the priority action to dilute and flush out the chemical, reducing the risk of further injury.

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Correct Answer is C

Explanation

A. Reorienting confused patients is important but is not directly related to cerebellar injury.

B. While turning every 2 hours is important to prevent pressure injuries, it does not address the specific fall risk associated with cerebellar damage.

C. The cerebellum is responsible for balance and coordination, so injuries in this area increase the risk of falls. Ensuring the bed alarm is on provides immediate alerts if the patient attempts to get out of bed, helping to prevent falls.

D. Varying the schedule to prevent boredom is not a priority in the care of patients with cerebellar injury.

A. Abnormal sensory sensations including tingling of the skin B. Yellowing of the skin C. Severe itching of the eyes D. Is in a drowsy confused state after a seizure

Correct Answer is D

Explanation

A. Abnormal sensory sensations such as tingling may be associated with the aura phase of a seizure but are not typically observed postictally.

B. Yellowing of the skin is usually indicative of jaundice, unrelated to seizure activity or the postictal state.

C. Itching of the eyes is unrelated to seizure activity and would not typically be documented in the context of postictal observations.

D. The postictal state is characterized by drowsiness, confusion, and other altered mental statuses that follow a seizure. This period can vary in duration depending on the patient and seizure type.

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The emergency department nurse is caring for a patient who has had a chemical splash in both eyes. What is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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The emergency department nurse is caring for a patient who has had a chemical splash in both eyes. What is the priority nursing action?