A patient presents with a penetrating eye injury caused by a small metal particle. What is the most immediate nursing intervention?
Cover the affected eye with a protective shield and seek immediate ophthalmic consultation.
Administer analgesics to manage pain before addressing the eye injury.
Apply pressure to the eye to prevent bleeding.
Irrigate the eye with sterile saline to remove the foreign object.
The Correct Answer is A
A. Cover the affected eye with a protective shield and seek immediate ophthalmic consultation: With a penetrating eye injury, the foreign object must never be removed, as this can cause further damage or extrusion of ocular contents. The priority is to immobilize the object and protect the eye using a rigid shield or cup (like a paper cup) and then obtain immediate specialist consultation (ophthalmologist). Both eyes should be covered to limit involuntary movement of the injured eye.
B. Administer analgesics to manage pain before addressing the eye injury: While pain management is important, the priority is preventing permanent vision loss or increasing the injury, which is a life-changing emergency. Pain medication can be administered after the protective shield is placed and the physician is notified.
C. Apply pressure to the eye to prevent bleeding: This is absolutely contraindicated. Applying pressure to an eye with a penetrating injury can increase intraocular pressure, potentially forcing the contents of the eye out and causing permanent damage.
D. Irrigate the eye with sterile saline to remove the foreign object: Irrigation is appropriate for chemical burns or superficial debris, but for a penetrating object, any attempt at removal or irrigation can cause movement, leading to severe damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Mechanical debridement: This involves using a wet-to-dry dressing or wound irrigation. It is non-selective (can damage healthy tissue) and not the most rapid method, especially for heavily infected wounds.
B. Autolytic debridement: This uses the body's own enzymes (via moisture-retentive dressings like hydrocolloids) to break down necrotic tissue. It is slow and generally contraindicated in heavily infected wounds because sealing the wound can create an anaerobic environment, potentially worsening the infection.
C. Surgical debridement: Surgical (sharp) debridement is the fastest and most effective method for removing large amounts of non-viable, infected, and exudative tissue. A heavily infected wound needs immediate reduction of the bioburden, which surgical debridement achieves quickly, moving the wound toward the healing phase.
D. Enzymatic debridement: This uses topical chemical enzymes (e.g., collagenase). It is slower than surgical debridement and often less effective at rapidly clearing the large amount of debris expected in a heavily exudative, infected wound.
Correct Answer is B
Explanation
A. Massage the reddened area to improve circulation:Massaging a reddened area (likely a Stage 1 pressure injury) can cause further damage to the underlying blood vessels and increase the risk of deeper tissue injury.
B. Apply a moisture barrier cream to the sacral area: This is a crucial intervention, especially if the client is incontinent, as it protects the skin from chemical irritation and maceration. However, it does not address the primary cause: unrelieved pressure.
C. Reposition the client every 4 hours: For a bedridden client with signs of breakdown, the standard of care requires repositioning at least every 2 hours (and often more frequently) to significantly reduce the risk of tissue ischemia caused by prolonged pressure. Repositioning every 4 hours is inadequate.
D. Elevate the head of the bed to 45°: The head of the bed should be kept at or below 30° (unless medically contraindicated) to minimize the effects of shear and friction on the skin of the sacrum and coccyx. Elevating to 45° increases shear and pressure risk.
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