A nurse is caring for an unconscious client who has a loss of the corneal reflex. Which of the following actions should the nurse take?

Clean the eyes with a mild soap.

Alternate warm saline compresses to the eyes.

Keep the room darkened.

Apply lubricating eye drops.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Soap is irritating to the eyes and can cause injury, especially when the protective corneal reflex is absent.
B. Warm saline compresses are not appropriate eye protection and can increase the risk of infection.
C. Darkening the room may reduce stimulation but does not protect the eyes from dryness or injury.
D. Loss of the corneal reflex prevents blinking, which normally keeps the eyes moist. Lubricating drops or ointments help protect the cornea from drying and injury.

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Correct Answer is D

Explanation

Rationale:
A. Purulent drainage is thick, yellow, green, or brown, indicating infection due to the presence of white blood cells, bacteria, and debris.
B. Sanguineous drainage is primarily blood, appearing bright red and thicker, not watery.
C. Serous drainage is clear or pale yellow and watery, composed mostly of serum, not blood.
D. Serosanguineous drainage is thin and watery with a pink to red color, indicating a mixture of blood and serous fluid. This is commonly seen in healing wounds.

A. Breakthrough pain B. Referred pain C. Neuropathic pain D. Somatic pain

Correct Answer is A

Explanation

Rationale:
A. Breakthrough pain is a sudden, intense flare of pain that occurs even though the patient is receiving around-the-clock analgesia (such as a fentanyl patch). It requires fast-acting supplemental medication.
B. Referred pain is felt in a location different from its source (e.g., shoulder pain from gallbladder disease).
C. Neuropathic pain results from nerve damage and is typically described as burning, tingling, or shooting, not sudden breakthrough pain.
D. Somatic pain originates in bones, joints, muscles, or skin. While the patient may have somatic pain, the description of sudden severe pain despite ongoing analgesia defines breakthrough pain.

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A nurse is caring for an unconscious client who has a loss of the corneal reflex. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?

Correct Answer is D

Explanation

A patient who has had good control for chronic pain using a fentanyl (Duragesic) patch reports rapid onset pain at a level 9 (0 to 10 scale) and requests "something for pain that will work quickly." How will the nurse document the type of pain reported by this patient?

Correct Answer is A

Explanation

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