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 C

Explanation

Choice A rationale

Auscultating for wheezing is important but not the first action. The priority is to administer epinephrine to counteract the severe allergic reaction.

Choice B rationale

Assessing the client’s level of consciousness is important but not the first action. Administering epinephrine takes precedence to stabilize the client’s condition.

Choice C rationale

Administering epinephrine is the first action. It is crucial to counteract the severe allergic reaction and prevent further complications.

Choice D rationale

Monitoring for hypotension is important but not the first action. Administering epinephrine is the priority to stabilize the client’s condition.

A. Avoid the use of insect repellent on the skin and clothing because of its toxicity. B. Avoid heavily wooded areas and areas with thick underbrush. C. Wear dark clothing when walking in wooded areas. D. Wear long-sleeved tops and long pants with closed shoes. E. If a tick is found, report to the primary health care provider immediately for a blood test to detect the presence of Lyme disease. F. Bathe after being in an infested area and inspect the body carefully for ticks.

Correct Answer is ["B","D","F"]

Explanation

Choice A rationale

Avoiding the use of insect repellent on the skin and clothing is not recommended. Insect repellents containing DEET are effective in preventing tick bites, which can transmit Lyme disease. The toxicity of DEET is minimal when used as directed.

Choice B rationale

Avoiding heavily wooded areas and areas with thick underbrush is recommended to reduce the risk of tick exposure. Ticks that carry Lyme disease are commonly found in these environments.

Choice C rationale

Wearing dark clothing is not recommended as it makes it harder to spot ticks. Light-colored clothing is preferable as it allows for easier detection of ticks.

Choice D rationale

Wearing long-sleeved tops and long pants with closed shoes is recommended to minimize skin exposure and reduce the risk of tick bites.

Choice E rationale

Reporting to the primary health care provider immediately for a blood test if a tick is found is not necessary. The presence of a tick does not immediately indicate Lyme disease. Instead, the tick should be removed promptly, and the area should be monitored for signs of infection.

Choice F rationale

Bathing after being in an infested area and inspecting the body carefully for ticks is recommended. This helps in early detection and removal of ticks, reducing the risk of Lyme disease.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who is suspected to have anaphylaxis following a bee sting. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

Which instructions would the nurse provide to the client about the prevention and early detection of Lyme disease? Select all that apply.

Correct Answer is ["B","D","F"]

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?