The emergency department nurse is caring for a patient who has had a chemical splash in both eyes. What is the priority nursing action?
Instill anesthetic eye drops in both eyes
Perform a visual acuity exam
Determine the pH of the chemical splash
Irrigate both eyes with normal saline
The Correct Answer is D
A. Anesthetic eye drops can help with pain, but irrigation is the priority to prevent further damage.
B. A visual acuity exam is part of the assessment but should be performed after initial irrigation to prevent further damage.
C. Determining the pH of the chemical splash can guide further treatment but is secondary to immediate irrigation to dilute and remove the chemical.
D. Irrigating both eyes with normal saline is the priority action to dilute and flush out the chemical, reducing the risk of further injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Using a draw sheet may cause twisting, which can compromise spinal alignment.
B. Asking the patient to assist may risk further spinal injury.
C. Turning hips and shoulders separately risks disrupting spinal alignment, making this an unsafe approach.
D. Log rolling is the safest way to turn a patient with a spinal cord injury, maintaining spinal alignment and preventing further injury. It requires one person to stabilize the head while others turn the body as a single unit.
Correct Answer is B
Explanation
A. 1:1 observation may be excessive unless the behavior is persistent and unmanageable.
B. Pointing out the behavior as unacceptable provides immediate feedback and helps the patient understand social boundaries, which can be challenging post-brain injury. This approach is direct and respectful, focusing on redirection rather than punishment.
C. Asking why may not be effective, as the patient may lack insight into their behavior due to the brain injury.
D. Having the patient return to their room could seem punitive and does not address the need for behavior modification.
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