Which action will prevent spreading organisms from one eye to the other when bathing a client?

Wipe from the outer part of the eye toward the inner portion.

Rinse the washcloth before washing the second eye.

Ask the client to roll the eyes upward.

Use a fresh washcloth when cleaning each eye.

Answer and Explanation

The Correct Answer is D

Use a fresh washcloth when cleaning each eye. This is because using the same washcloth for both eyes can transfer microorganisms from one eye to the other and cause cross-infection.

The other choices are wrong because:

Choice A is wrong because wiping from the outer part of the eye toward the inner portion can introduce microorganisms into the tear ducts and cause infection.

Choice B is wrong because rinsing the washcloth before washing the second eye does not eliminate all the microorganisms that might be on the cloth.

Choice C is wrong because asking the client to roll the eyes upward does not prevent spreading organisms from one eye to the other when bathing a client.

Normal ranges for eye hygiene are to use a clean washcloth or cotton ball for each eye, wipe from the inner to the outer canthus, and use warm water or saline solution.

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Correct Answer is C

Explanation

Determining whether chest pain has been relieved. This is because nitroglycerin is a medication that is used to treat chest pain caused by cardiac origin or acute pulmonary edema. The main action of nitroglycerin is to relax and dilate the blood vessels, which reduces the workload of the heart and improves blood flow to the heart muscle.

Therefore, the most important nursing action after administering nitroglycerin sublingually is to assess if the chest pain has subsided or not.

Choice A is wrong because monitoring the client’s respiratory rate and effort is not the most important action after giving nitroglycerin. Although nitroglycerin can cause hypotension and bradycardia, which may affect the respiratory status, these are side effects that can be managed and are not life-threatening as chest pain.

Choice B is wrong because warning the client to lie still to prevent a headache is not a priority after giving nitroglycerin. Nitroglycerin can cause headache as a side effect, but this can be treated with analgesics and does not require the client to lie still. Moreover, lying still may increase the risk of venous thromboembolism in a client with peripheral vascular disease.

Choice D is wrong because verifying that the sublingual tablet produced a tingling sensation is not essential after giving nitroglycerin.

Although some sublingual tablets may produce a tingling sensation, this is not a reliable indicator of the drug’s effectiveness

A. Offering thickened liquids. B. Placing client in upright position. C. Providing large, frequent bites. D. Allowing ample time between choices.

Correct Answer is C

Explanation

This action would cause the nurse to intervene because it increases the risk of choking and aspiration for a client with dysphagia, which is difficulty swallowing. The nurse would instruct the UAP to feed the client small amounts of food slowly, allowing time for chewing and swallowing.

Choice A is wrong because offering thickened liquids is a safe practice for a client with dysphagia. Thickened liquids allow for easier swallowing and less choking, thus decreasing the chance of aspiration.

Choice B is wrong because placing the client in an upright position is also a safe practice for a client with dysphagia. This position helps prevent food from entering the airway and facilitates swallowing.

Choice D is wrong because allowing ample time between bites is another safe practice for a client with dysphagia. This helps the client avoid feeling rushed or overwhelmed and reduces the risk of aspiration.

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Which action will prevent spreading organisms from one eye to the other when bathing a client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing action is most important after administering nitroglycerin sublingually?

Correct Answer is C

Explanation

The unlicensed assistive personnel (UAP) is feeding a client with dysphagia. What action would cause the nurse to intervene?

Correct Answer is C

Explanation

A client has been newly diagnosed with hypothyroidism. What symptoms or signs would be expected with this diagnosis? Select all that apply.

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