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:

To an insurance agency in regard to a life insurance policy . This situation is incorrect. Generally, disclosure of health information to an insurance agency requires the client's written consent.

Choice B Reason:

To a medical interpreter service on behalf of a client. This situation is correct. In healthcare settings, it is generally acceptable to share limited health information with a medical interpreter service to facilitate communication with the client, especially if the client has limited proficiency in the primary language spoken in the healthcare setting. The interpreter is bound by confidentiality rules similar to healthcare providers.

Choice C Reason:

To a family member when the client is not available. This situation is incorrect. Disclosing health information to a family member typically requires the client's consent unless there are specific circumstances, such as emergencies, where the healthcare provider may need to act in the best interest of the client.

Choice D Reason:

To an employer for a pre-employment screening. This situation is incorrect. Disclosing health information to an employer typically requires the client's written consent. Employment-related health information is usually protected by privacy laws.

A. Add 0.5 mL of diluent to the medication. B. Cleanse the tip of the ampule with an alcohol swab after opening. C. Use a filter needle to aspirate the medication. D. Inject air into the ampule prior to drawing the medication into a syringe.

Correct Answer is C

Explanation

Choice A Reason:

Adding 0.5 mL of diluent to the medication is inappropriate action. Ampules typically contain a single-dose of medication in a liquid form, and dilution is not necessary unless specified by the medication order or manufacturer.

Choice B Reason:

This is not necessary as the tip of the ampule is already sterile before opening. Cleansing after opening does not provide additional benefit and can introduce contaminants.

Choice C Reason:

Using a filter needle to aspirate the medication is inappropriate. Filter needles are not routinely used for administering medication from ample.

Choice D Reason:

This is not appropriate for ampules. Unlike vials, ampules do not require air to be injected. Air injection is necessary only for vials to create pressure, but ampules are opened and medication is drawn directly without the need for air.

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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 nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations nurse disclose health information without the client's written consent?

Correct Answer is B

Explanation

A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

Correct Answer is C

Explanation

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