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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Keep her arms at the sides of her body with her hands in a relaxed position is wrong. Keeping the hands in a relaxed position at the sides of the body may increase the risk of accidental contact with non-sterile surfaces.
Choice B Reason:
Interlock her fingers and hold her hands away from her body above her waist is wright. Interlocking fingers and holding hands above the waist may increase the risk of accidental contact with non-sterile surfaces.
Choice C Reason:
Clasp her hands together in a relaxed position behind her body at her waist is wrong. This positioning helps maintain sterility by keeping the hands away from potential contaminants and below the waist level. Placing the hands behind the body avoids accidental contact with non-sterile surfaces or objects.
Choice D Reason:
Place one hand over the other against the part of the gown covering her upper body is wrong. Placing hands on the gown covering the upper body may lead to contamination, as the gown is considered non-sterile on the outside. The hands should be kept in a position that minimizes the risk of contact with non-sterile surfaces.
Correct Answer is A
Explanation
A client can withdraw consent at any time. This statement is accurate. Informed consent is a process that involves providing the client with information about a procedure or treatment, including its risks and benefits, to enable them to make an informed decision. A client has the right to withdraw their consent at any point in the process.
Choice B Reason:
A family member should witness the client's consent. The witnessing of informed consent is typically done by a healthcare professional involved in the procedure or a neutral third party, not a family member.
Choice C Reason:
A nurse is responsible for obtaining informed consent. While nurses may assist with the informed consent process by providing information and answering questions, the ultimate responsibility for obtaining informed consent usually lies with the healthcare provider performing the procedure.
Choice D Reason:
A minor who is pregnant is unable to give consent. The ability of a minor to give consent can vary based on jurisdiction and the specific circumstances. In many cases, minors may be able to provide consent for certain medical procedures, particularly if they are deemed mature enough to understand the implications. Being pregnant might not necessarily preclude a minor from giving consent. Legal and ethical considerations regarding minors' consent can vary, and healthcare providers should be aware of local regulations and guidelines.
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