A nurse in a provider's office is caring for a client who has blepharitis. Which of the following actions should the nurse take first?

Reinforce teaching with the client about proper instillation of antibiotic eye drops.

Apply warm compresses to the affected eye.

Dim the lights in the client examination room.

Inspect the eyes for drainage or redness.

Answer and Explanation

The Correct Answer is D

Choice A reason: This is an important action, but not the first one. The nurse should first address the client's comfort and inflammation before teaching them how to use the eye drops.

Choice B reason: Option B (warm compresses) is a key intervention for blepharitis to improve meibomian gland function and reduce crusting. However, assessment (Option D) must precede treatment to ensure no contraindications (e.g., corneal abrasion) and tailor care appropriately.

Choice C reason: This is a helpful action, but not the first one. The nurse should first apply warm compresses to the affected eye, and then dim the lights to reduce the sensitivity and pain.

Choice D reason: The first step in the nursing process is assessment. Even with a diagnosis of blepharitis, the nurse must inspect the eyes to evaluate the current severity, presence of drainage (e.g., purulent vs. serous), redness, or signs of secondary infection (e.g., bacterial involvement). This informs subsequent interventions.

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Correct Answer is B

Explanation

Choice A reason: This is a nonspecific finding, because a report of a severe headache can be caused by many factors, such as concussion, migraine, or tension. A headache alone is not an indication of a skull fracture.

Choice B reason: This is a specific finding, because clear fluid coming from the nares can indicate a cerebrospinal fluid (CSF) leak, which is a sign of a basilar skull fracture. CSF is the fluid that surrounds and protects the brain and spinal cord, and can leak through the nose or ears if the skull is fractured.

Choice C reason: This is a nonspecific finding, because a brief change in level of consciousness can be caused by many factors, such as hypoxia, hypoglycemia, or seizure. A change in level of consciousness alone is not an indication of a skull fracture.

Choice D reason: This is a nonspecific finding, because bleeding from the top of the scalp can be caused by many factors, such as laceration, abrasion, or contusion. Bleeding from the scalp alone is not an indication of a skull fracture.

A. A client who has benign prostate hyperplasia (BPH) and reports dysuria B. A client who has ulcerative colitis and reports diarrhea C. A client who has emphysema and reports dyspnea D. A client who has esophageal cancer and reports painful swallowing

Correct Answer is C

Explanation

Choice A reason: A client who has BPH and reports dysuria is not the highest priority, because dysuria is a common symptom of BPH and does not indicate an acute complication. The nurse should monitor the client's urinary output and provide comfort measures.

Choice B reason: A client who has ulcerative colitis and reports diarrhea is not the highest priority, because diarrhea is a chronic symptom of ulcerative colitis and does not indicate an acute complication. The nurse should assess the client's hydration status and electrolyte levels and administer medications as prescribed.

Choice C reason: A client who has emphysema and reports dyspnea is the highest priority, because dyspnea is a sign of respiratory distress and can indicate an acute exacerbation of emphysema. The nurse should assess the client's oxygen saturation and respiratory rate and administer oxygen therapy as prescribed.

Choice D reason: A client who has esophageal cancer and reports painful swallowing is not the highest priority, because painful swallowing is a common symptom of esophageal cancer and does not indicate an acute complication. The nurse should provide the client with soft or liquid foods and administer analgesics as prescribed.

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A nurse in a provider's office is caring for a client who has blepharitis. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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