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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Avoiding sexual intercourse under the influence of drugs reduces certain risks but does not address the specific risk of needle transmission.

B. Asking others to be tested for HIV may be unrealistic and does not prevent HIV transmission through shared equipment.

C. Participating in a needle exchange program reduces the risk of HIV transmission by providing sterile needles, lowering the likelihood of infection from shared or contaminated needles.

D. Cleaning needles with betadine is not effective for HIV prevention; only sterile, unused needles should be used.

A. Altered mental status B. Tachycardia and hypotension C. Fixed and dilated pupils D. Widening pulse pressure

Correct Answer is A

Explanation

A. Altered mental status, such as confusion, restlessness, or lethargy, is often the earliest sign of increasing ICP as it reflects brain tissue compression.

B. Tachycardia and hypotension are not primary indicators of elevated ICP.

C. Fixed and dilated pupils indicate severe and often irreversible ICP increase, occurring later in the progression.

D. Widening pulse pressure is a later sign of increased ICP, following changes in mental status.

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The emergency department nurse is caring for a patient who has had a chemical splash in both eyes. What is the priority nursing action?

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