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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Removing objects is contraindicated, as it can worsen the injury.
B. Stabilizing the object and covering it prevents further injury until medical evaluation, which is critical in cases of eye trauma. Moving or removing a foreign body could lead to additional damage.
C. Providing a light meal is not directly related to managing eye trauma and does not address the immediate concern.
D. Blowing the nose could increase intraocular pressure, potentially worsening the injury.
Correct Answer is A
Explanation
A. Frequent passive range of motion exercises are crucial for preventing complications of immobility, such as contractures and pressure ulcers, and to promote circulation in patients with spinal cord injuries.
B. While coughing and deep breathing exercises are important for respiratory health, they should be performed more frequently than once per shift in patients with reduced mobility to prevent respiratory complications.
C. Turning the patient every 4 hours may not be adequate to prevent pressure ulcers; typically, patients should be turned at least every 2 hours.
D. Patients with a complete spinal cord injury at C7 typically lack the ability to ambulate, making this intervention inappropriate.
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