A nurse is performing eye care for a client who is in a coma. Which of the following actions should the nurse take? (Select all that apply.)

Wipe the eyes from the outer to the inner canthus.

Apply eye patches over the eyes if the eyelids do not close completely.

Cleanse the eyes with a chlorhexidine solution.

Place moist compresses over the eyes every 2 to 4 hr.

Instill lubricating eye drops into the lower lid of each eye.

Answer and Explanation

Correct Answer : B,D,E

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 eye is appropriate. Lubricating eye drops help prevent dryness and maintain eye moisture, offering protection to the cornea.

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Correct Answer is B

Explanation

Choice A Reason:
"He may need a feeding tube" is inappropriate response. Suggesting a feeding tube without further assessment or information might be premature and could cause unnecessary concern or anxiety for the son. It's essential to explore the situation more before proposing such an intervention.

Choice B Reason:
"Tell me more about what happens at mealtime” is appropriate response. This response encourages the son to provide further details about the situation, allowing the nurse to gather more information about the specific issues or challenges related to the client's eating habits. Understanding the circumstances around mealtime can help the nurse identify potential reasons for the lack of appetite or eating difficulties and offer more targeted guidance or solutions.

Choice C Reason:
"Why do you think he's not eating?" This response is inappropriate. While asking about the son's thoughts is valuable, this question might not directly address the situation at hand or provide immediate assistance or guidance to address the client's eating difficulties.

Choice D Reason:
"I'm sure it's nothing serious and his appetite will return soon” is inappropriate response. Offering reassurance without understanding the underlying cause may downplay a potentially concerning issue. It's crucial to investigate the reasons behind the lack of appetite before assuming it will resolve without further action.

A. Request a medication reconciliation form from the pharmacy. B. Ask the client if she received the 1700 medication. C. Contact the previous nurse to determine if the client received the medication. D. Administer the medication and document the current time.

Correct Answer is C

Explanation

Choice A Reason:

Requesting a medication reconciliation form from the pharmacy is not the immediate step needed for a missed dose. Contacting the previous nurse provides more timely information.

Choice B Reason:

Asking the client if she received the 1700 medication is not the first action to take. The nurse should first investigate the missing documentation through collaboration with the healthcare team.

Choice C Reason:

Contacting the previous nurse to determine if the client received the medication is correct. Contacting the previous nurse is a reasonable and responsible step to gather information about the missed medication. The previous nurse may have insights into why the documentation is missing and whether the medication was administered.

It allows for collaboration and communication among healthcare providers, ensuring accurate and comprehensive information about the client's care. Administering the medication without clarification may lead to a potential double dose if the previous dose was indeed administered.

Choice D Reason:

Administering the medication and documenting the current time without confirming the missed dose could result in an inaccurate representation of the client's medication history and potential harm if the previous dose was already administered. It is crucial to gather information before taking further action.

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A nurse is performing eye care for a client who is in a coma. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is reinforcing teaching about dietary needs with the son of a client. The son states, "I don't know what to do because he's not eating." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is reviewing a client's medication administration record at 1930. The nurse notes that the documentation for the 1700 regular insulin dose is missing. Which of the following is an appropriate action for the nurse to take?

Correct Answer is C

Explanation

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