A client presents in the emergency room with a penetrating eye injury. The object is still present in the eye. Which nursing action is priority?

Stabilize the object

Apply anesthetic drops

Remove the object

Apply eye ointment

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the correct answer because stabilizing the object is the priority nursing action for a penetrating eye injury. Stabilizing the object prevents further damage to the eye structures and reduces the risk of infection and bleeding. The nurse should use a protective shield or cup to cover the eye and secure the object in place, and avoid applying any pressure or movement to the eye.

Choice B reason: This is not the correct answer because applying anesthetic drops is not the priority nursing action for a penetrating eye injury. Anesthetic drops may provide some relief from pain and discomfort, but they do not address the underlying problem of the object in the eye. Anesthetic drops should only be used under the direction of a physician, and after the object has been stabilized.

Choice C reason: This is not the correct answer because removing the object is not the priority nursing action for a penetrating eye injury. Removing the object is a surgical procedure that should only be performed by a qualified physician in a sterile environment. Attempting to remove the object by the nurse may cause more harm to the eye and increase the risk of complications.

Choice D reason: This is not the correct answer because applying eye ointment is not the priority nursing action for a penetrating eye injury. Eye ointment may interfere with the visualization and assessment of the eye, and may also contaminate the wound and cause infection. Eye ointment should only be used under the direction of a physician, and after the object has been stabilized.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is E

Explanation

Choice A reason: Assessment is the first phase of the nursing process, where the nurse collects data about the patient's health status, needs, preferences, and goals.

Choice B reason: Analysis/Diagnosis is the second phase of the nursing process, where the nurse interprets the data and identifies the patient's problems, risks, and strengths.

Choice C reason: Planning is the third phase of the nursing process, where the nurse develops a care plan that specifies the expected outcomes, interventions, and priorities for the patient.

Choice D reason: Implementation is the fourth phase of the nursing process, where the nurse executes the care plan and performs the interventions for the patient.

Choice E reason: Evaluation is the fifth and final phase of the nursing process, where the nurse measures the effectiveness of the interventions and compares the actual outcomes with the expected outcomes. Asking the patient about their pain level after giving pain medication is an example of evaluation.

A. Identification B. Denial C. Displacement D. Rationalization

Correct Answer is D

Explanation

Choice A reason: Identification is a defense mechanism where the person adopts the characteristics or behaviors of someone else, usually someone more powerful or successful, to cope with feelings of inadequacy or insecurity.

Choice B reason: Denial is a defense mechanism where the person refuses to accept or acknowledge the reality of a situation or a problem, to avoid dealing with the negative emotions or consequences.

Choice C reason: Displacement is a defense mechanism where the person transfers their feelings or impulses from the original source to a less threatening or more acceptable one, to reduce the anxiety or guilt.

Choice D reason: Rationalization is a defense mechanism where the person uses logical or plausible explanations to justify or excuse their actions or behaviors, to avoid facing the true motives or reasons.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client presents in the emergency room with a penetrating eye injury. The object is still present in the eye. Which nursing action is priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Twenty minutes after administering pain medication to the patient, the nurse asks if the patient's pain level has decreased. What phase of the nursing process does this demonstrate?

Correct Answer is E

Explanation

A nurse is caring for a client who states, "I did not take my medication because my partner forgot to remind me." The nurse should identify that the client is demonstrating which of the following defense mechanisms?

Correct Answer is D

Explanation

The RN is using clinical judgment to determine which patient she needs to see first. What is one primary reason for prioritizing care?

When shown an Amsler grid, the client reports seeing wavy, distorted lines. The client also states his center of vision is dark and he has no sense of depth perception. The nurse suspects the client has which of the following conditions?

The RN receives a call from the lab that a client's potassium chloride (KCl) level is 6.6 (normal range is 3.5 to 5 mEq/L). What should the nurse do first?

A client presents in the emergency room with a penetrating eye injury. The object is still present in the eye. Which nursing action is priority?

A nurse is collecting data from a client who has open-angle glaucoma. Which of the following symptoms should the nurse expect the patient to report?

A nurse is providing skin care for a client who has urinary incontinence. Which of the following actions should the nurse take?

A person is experiencing stress because they are worried about passing their driver's license test tomorrow. This is an example of what type of stress?

The nurse is caring for an older adult client who is receiving intravenous fluids at 150 mL/hr. Upon assessment, the nurse notes crackles, shortness of breath, and jugular vein distention. Based on this data, which complication of IV fluid therapy does the nurse anticipate?