The nurse is caring for a client with a penetrating eye injury. Which action is appropriate for the nurse to include in the plan of care?
A) Apply anesthetic drops.
B) Apply eye ointment.
C) Remove the foreign body.
D) Stabilize the penetrating object.
Answer: D
For a severe or penetrating injury, promote rest and stabilize the injured eye by applying an eye pad or gauze dressing loosely over both the affected and unaffected eye. Stabilize any penetrating object, if possible. These measures reduce eye movement and can help preserve the client's vision. Anesthetic drops would be appropriate prior to the removal of a foreign body from the eye. Removal of the foreign body is appropriate if the client had a foreign body in the eye. Application of eye ointment would be applicable after the removal of a foreign body or for a corneal abrasion.
You might also like to view...
The nurse is caring for a 22-year-old female patient who is 2 days post craniotomy for a brain tumor. She was doing well until 2 a.m., when she begins crying and asks for her mother
She has a Glasgow Coma Scale (GCS) of 15, and pupils are equal and reactive. Her mother is sleeping in the visitors' lounge. What nursing action would be most appropriate at this time? a. Administer an as-needed sedative to calm the patient. b. Notify the neurosurgeon that the patient is upset and crying. c. Ask the mother to come and stay with the patient. d. Reassure the patient, and sit with her until she falls back asleep.
A patient who has received a heart transplant is taking cyclosporine, an immunosuppressant. What should the nurse emphasize during health education about infection prevention?
A) Eat a high-calorie, high-protein diet. B) Limit physical activity in order to conserve energy. C) Take prophylactic antibiotics as ordered. D) Perform frequent handwashing.
A client with cryptorchidism is being seen at the infertility clinic. The nurse gives high priority to including which instruction?
1. Advising the client to seek the assistance of a sex counselor 2. Teaching testicular self-exam (TSE) due to risk for testicular cancer 3. Avoiding the use of scrotal support devices 4. Avoiding strenuous activity
Given the main functions of the autonomic nervous system (ANS), which nursing action would be a priority consideration in providing care for clients with an autonomic dysfunction?
1. Providing information for urodynamic testing 2. Monitoring cardiac rhythms 3. Performing a mental status assessment 4. Administering antacids