A nurse is caring for a client who is postoperative following a left corneal transplant.

The nurse observes purulent drainage from the affected eye.

Which of the following actions is the nurse’s priority?

Apply a non-pressure patch to the affected eye.

Clean the eye from inner to outer canthus.

Notify the surgeon.

Instill an antibiotic solution in both eyes.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Applying a non-pressure patch to the affected eye can help protect the eye from further irritation or injury. However, it does not address the underlying issue of purulent drainage, which could indicate an infection that requires immediate medical attention.

Choice B rationale

Cleaning the eye from inner to outer canthus is a standard practice to prevent the spread of infection. However, in this case, the presence of purulent drainage suggests a possible infection that needs to be evaluated by a surgeon.

Choice C rationale

Notifying the surgeon is the priority action because purulent drainage from the eye can indicate a serious infection or complication following surgery. Immediate medical evaluation and intervention are necessary to prevent further complications and ensure proper treatment.

Choice D rationale

Instilling an antibiotic solution in both eyes may be part of the treatment plan for an infection. However, the nurse should first notify the surgeon to get appropriate orders and ensure that the correct antibiotic and treatment plan are followed.

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Correct Answer is A

Explanation

Choice A rationale

Shutting off the intravenous infusion is the immediate action to take when a client reports difficulty swallowing during infliximab infusion. This could indicate an infusion reaction or anaphylaxis, which requires immediate cessation of the infusion to prevent further complications.

Choice B rationale

Notifying the primary health care provider is important, but the immediate action should be to stop the infusion to prevent further adverse reactions.

Choice C rationale

Having the client take deep breaths and try to relax is not appropriate in this situation, as it does not address the potential infusion reaction or anaphylaxis.

Choice D rationale

Obtaining a prescription for oral diphenhydramine may be part of the treatment for an infusion reaction, but the immediate action should be to stop the infusion. .

A. Headaches and blurred vision. B. Tremors and weakness. C. Rash symptoms. D. Painful joints.

Correct Answer is C

Explanation

Choice A rationale

Headaches and blurred vision are not specific to stage I Lyme disease. These symptoms can occur in many other conditions and are not the primary indicators of early Lyme disease.

Choice B rationale

Tremors and weakness are not typical early signs of Lyme disease. These symptoms are more associated with neurological involvement, which occurs in later stages of the disease.

Choice C rationale

Rash symptoms, specifically erythema migrans (a bull’s-eye rash), are the hallmark of stage I Lyme disease. This rash appears at the site of the tick bite and is a key diagnostic feature.

Choice D rationale

Painful joints are more commonly seen in later stages of Lyme disease when the infection has spread and caused more systemic involvement.

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A nurse is caring for a client who is postoperative following a left corneal transplant. The nurse observes purulent drainage from the affected eye. Which of the following actions is the nurse’s priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receiving infliximab through intravenous infusion is reporting difficulty swallowing. Which immediate action would the nurse take?

Correct Answer is A

Explanation

A client calls the health care clinic and asks the nurse to describe the first signs of Lyme disease. The nurse informs the client to watch for which signs/symptoms of stage I Lyme disease?

Correct Answer is C

Explanation

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A nurse is caring for a client who is postoperative following a left corneal transplant.

The nurse observes purulent drainage from the affected eye.

Which of the following actions is the nurse’s priority?