A nurse is caring for a client who is scheduled for a CT scan that requires contrast dye. Which of the following actions is the priority for the nurse to take?

Question the client about allergies before the procedure.

Tell the client to increase fluid intake following the procedure.

Evaluate the client for claustrophobia.

Inform the client about the steps of the procedure.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Questioning the client about allergies before the procedure is appropriate. It is crucial to assess the client for any allergies, especially to contrast dye, before the procedure. Allergic reactions to contrast dye can range from mild to severe, and prompt identification of potential allergies is essential to prevent adverse reactions. If the client has a known allergy to the contrast dye, alternative imaging methods or pre-medication may be considered.

Choice B Reason:

Telling the client to increase fluid intake following the procedure is inappropriate. This instruction is relevant post-procedure for the elimination of the contrast dye from the body. However, it is not the priority at this moment, and the client's safety during the procedure takes precedence.

Choice C Reason:

Evaluating the client for claustrophobia is appropriate. Assessing for claustrophobia is important, especially if the CT scan involves an enclosed space. However, this assessment can typically be conducted in advance of the procedure during the pre-procedure preparations.

Choice D Reason:

Informing the client about the steps of the procedure is inappropriate. Providing information about the procedure is important for the client's understanding and cooperation. However, ensuring the client's safety during the procedure by assessing for potential allergies to the contrast dye comes first.

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Correct Answer is E,C,D,B,A

Explanation

Choice E Reason:

Preparing a dry work surface above the waist level. It's crucial to start by selecting and preparing an appropriate area for setting up the sterile field. This surface needs to be clean, dry, and above the waist level to maintain sterility and prevent contamination.

Choice C Reason:

Opening the outside cover of the sterile kit and remove the dust cover. This step involves opening the sterile kit without touching the inside contents to maintain sterility. Removing the outer cover exposes the sterile packaging and prepares for further steps.

Choice D Reason:

Grasping the outermost flap of the sterile kit while opening away from the body. By carefully opening the outermost flap, the nurse ensures that the sterile contents remain protected. Opening away from the body helps prevent accidental contamination from clothing or movements.

Choice B Reason:

Opening each side flap of the sterile kit individually while pulling to the side. Sequentially opening the side flaps maintains the sterile field and allows access to the inner contents without compromising sterility.

Choice A Reason:

Opening the innermost lower flap of the sterile kit while standing away from the sterile field. This final step involves accessing the innermost contents of the sterile kit while maintaining a safe distance to avoid accidental contamination. It ensures the contents within the sterile field remain protected until needed for the dressing change.

A. Wipe the eyes from the outer to the inner canthus. B. Apply eye patches over the eyes if the eyelids do not close completely. C. Cleanse the eyes with a chlorhexidine solution. D. Place moist compresses over the eyes every 2 to 4 hr. E. Instill lubricating eye drops into the lower lid of each eye.

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

Explanation

Choice A Reason:

Wiping the eyes from the outer to the inner canthus is inappropriate. This direction of wiping might risk introducing contaminants into the eyes. It's generally advised to wipe from the inner to the outer canthus to minimize the risk of introducing potential eye irritants.

Choice B Reason:

Applying eye patches over the eyes if the eyelids do not close completely is appropriate. Eye patches help protect the eyes from potential damage, dryness, or exposure to light if the eyelids do not close fully.

Choice C Reason:

Cleansing the eyes with a chlorhexidine solution is inappropriate. Chlorhexidine solution might be too harsh for use around the delicate eye area and could cause irritation or damage to the eyes. Using a gentler and specifically formulated eye cleansing solution or sterile saline is usually recommended for eye care.

Choice D Reason:

Placing moist compresses over the eyes every 2 to 4 hours is appropriate. Moist compresses can help maintain moisture and prevent dryness in the eyes, reducing the risk of corneal damage due to the inability to blink.

Choice E Reason:

Instilling lubricating eye drops into the lower lid of each eyeis appropriate. Lubricating eye drops help prevent dryness and maintain eye moisture, offering protection to the cornea.

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