The nurse is caring for a patient who has sustained eye trauma as a result of a motor vehicle crash (MVC). Which intervention should the nurse provide regarding a foreign body?
Remove all foreign objects
Stabilize object and lightly protect with covering
Provide a light meal with clear liquids
Instruct the patient vigorously blow their nose if necessary
The Correct Answer is B
A. Removing objects is contraindicated, as it can worsen the injury.
B. Stabilizing the object and covering it prevents further injury until medical evaluation, which is critical in cases of eye trauma. Moving or removing a foreign body could lead to additional damage.
C. Providing a light meal is not directly related to managing eye trauma and does not address the immediate concern.
D. Blowing the nose could increase intraocular pressure, potentially worsening the injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Elevating the head of the bed, loosening clothing, and checking for urinary catheter obstruction are key steps to lower blood pressure and relieve triggers of autonomic dysreflexia, a potentially life-threatening condition.
B. A cool compress may provide comfort but does not directly address the primary triggers or symptoms of autonomic dysreflexia.
C. Semi-Fowler's position is insufficient compared to a full 90-degree sitting position, which helps reduce blood pressure.
D. IV access and oxygen may be required if symptoms do not resolve, but immediate actions focus on relieving the cause of dysreflexia.
Correct Answer is D
Explanation
A. Touching a patient’s shoulder does not pose a risk of HIV transmission, as it is not spread through casual skin contact.
B. While recapping needles is discouraged due to the risk of needlestick injury, it is not an exposure unless an actual needlestick occurs.
C. Not wearing a mask is typically not necessary in all interactions with HIV/AIDS patients unless there is an active infection requiring airborne precautions.
D. Exposure of bodily fluids to mucous membranes (such as the eyes) is a significant occupational exposure risk and should be reported. This requires immediate response and evaluation for potential infection.
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