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?

Choice A reason: White rice is not a food that can cause diarrhea, as it is a bland and starchy food that can help bind the stool and reduce the frequency of bowel movements.

Choice B reason: Ripe bananas are not a food that can cause diarrhea, as they are rich in potassium, which can help replenish the electrolytes lost due to diarrhea. They also contain pectin, a soluble fiber that can help firm up the stool.

Choice C reason: Low-fiber cereal is not a food that can cause diarrhea, as it is easy to digest and does not irritate the intestinal lining. It can also provide some energy and nutrients for the body.

Choice D reason: Prunes are a food that can cause diarrhea, as they are high in sorbitol, a sugar alcohol that can have a laxative effect and draw water into the colon. They also contain insoluble fiber, which can increase the bulk and speed of the stool.

Choice A reason: Assessment is the first and most important phase of the nursing process, as it involves collecting and analyzing data about the patient's health status, needs, and preferences. The nurse should have assessed the patient's blood pressure before administering the antihypertensive medication, as it could have been contraindicated or required a dosage adjustment. By failing to do so, the nurse put the patient at risk of hypotension and its complications.

Choice B reason: Planning is the second phase of the nursing process, in which the nurse sets goals and outcomes for the patient's care and selects appropriate interventions. The nurse did not make an error in this phase, as the administration of the antihypertensive medication was part of the plan of care for the patient with hypertension.

Choice C reason: Diagnosis is the third phase of the nursing process, in which the nurse identifies the patient's actual or potential health problems based on the assessment data. The nurse did not make an error in this phase, as the diagnosis of hypertension was accurate and supported by the patient's history and vital signs.

Choice D reason: Evaluation is the fourth and final phase of the nursing process, in which the nurse measures the patient's progress and outcomes and modifies the plan of care as needed. The nurse did not make an error in this phase, as the re-checking of the blood pressure and the recognition of the patient's symptoms were part of the evaluation process. However, the nurse should have also notified the provider and implemented interventions to treat the hypotension.