During assessment, a nurse notes that the client's right pupil is 2 mm larger than the left pupil. The nurse would first do which of the following?
A. Ask the client how long this condition has been present.
B. Attempt to elicit a red reflex in both eyes.
C. Document the finding as the only action.
D. Notify the physician.
A
Although both pupils are normally the same size and a difference in size can indicate a variety of pathologies, approximately 5% of people have a noticeable difference in the size of their pupils. The nurse should first determine if this condition represents a change or has been present for a long time.
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a. Skin b. Kidney c. Heart d. Lungs
When swelling occurs in the tissues surrounding the IV site, the nurse should first:
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