A nurse is assessing a client's lifestyle habits. Which of the following questions is most appropriate to identify risk factors affecting the mouth and throat?

A. "Apply an ice pack to the affected eye" is incorrect because cold compresses only provide temporary pain relief and may reduce inflammation slightly, but they do not facilitate drainage of the infected gland. Cold can limit circulation, which may slow the natural resolution of the stye.

B. "Place a warm compress on the eye" is the correct intervention and is considered the first-line treatment for styes. Warmth promotes vasodilation, which increases blood flow to the affected area, bringing immune cells to fight infection. It also softens the contents of the clogged gland, facilitating natural drainage of pus. The compress should be applied for 10–15 minutes at a time, 3–4 times per day. This approach reduces pain, decreases inflammation, and accelerates resolution of the stye. Warm compresses can be used safely at home and are non-invasive, making them ideal for initial management.

C. "When it comes to a head, try popping it" is dangerous and contraindicated. Attempting to squeeze or pop a stye can force bacteria deeper into the eyelid tissues, increase the risk of spreading infection, and may lead to cellulitis or permanent scarring. Even healthcare professionals avoid manual drainage unless necessary and performed under sterile conditions.

D. "Rub the eye gently to help it drain" is also incorrect. Rubbing can irritate the eyelid further, potentially spread infection to the conjunctiva or other areas, and worsen swelling or pain. Proper care involves gentle hygiene without mechanical manipulation.

A. There is no evidence of inappropriate behavior by the UAP. The UAP accurately reported the vital signs. There is no indication of misconduct or negligence that would require reporting to a manager.

B. Although one value is abnormal, the nurse should not delegate reassessment of an abnormal finding back to the UAP. When abnormal data are reported, the registered nurse is responsible for validating and further assessing the finding personally. Re-delegating does not meet the RN’s accountability for clinical judgment.

C. A pulse oximetry reading of 91% on room air is below normal (normal is 95–100%), indicating mild hypoxemia. However, before initiating an intervention such as oxygen therapy, the nurse must first validate the abnormal finding. Pulse oximetry readings can be affected by poor probe placement, cold extremities, nail polish, motion, or equipment error. Immediate oxygen administration without reassessment is premature.

D. A pulse oximetry of 91% is abnormal and requires follow-up. The nurse’s first action should be to personally reassess the oxygen saturation to validate the accuracy of the reading. This includes checking probe placement, ensuring proper perfusion, and assessing the client’s respiratory status. Once validated, appropriate interventions such as oxygen therapy can be initiated if necessary.