The practical nurse (PN) is assisting a client to the bathroom after a right cataract extraction. The client has an eye shield over the right eye. How should the PN assist the client during ambulation?
Place the client in front of the nurse while both walk to the bathroom.
Stand in front of the client and lead the client forward to the bathroom.
Walk on the client's left side while assisting the client to the bathroom.
Support the client on the right side while walking to the bathroom.
The Correct Answer is C
A. Placing the client in front of the nurse can be disorienting and unsafe, especially since the client has limited vision with the eye shield. The PN should be in a position to provide guidance and support.
B. Standing in front of the client while leading them could be confusing for the client, as they might not see where they are going. The PN should be positioned where they can offer clear support and direction.
C. Walking on the client’s left side is the best approach as it ensures that the PN is on the side of the unaffected eye. This position allows the PN to guide and support the client while the shielded eye is protected from potential hazards.
D. Supporting the client on the right side could interfere with the eye shield and the healing process. The PN should assist from the left side to avoid disturbing the protected eye and to provide better guidance.
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Related Questions
Correct Answer is D
Explanation
A. Determining if the spouse has medication allergies is unnecessary because the PN should not provide medication to anyone other than the patient. Medication administration policies are strict about who can receive medications and ensuring compliance with these policies is crucial for legal and safety reasons.
B. The PN cannot request medication for individuals who are not patients under their care, so this action does not follow hospital procedures. Medications must be administered through proper channels to ensure they are given safely and legally.
C. Giving medication from the nurse’s personal supply is a violation of hospital policy and professional ethics. All medications must be obtained through approved sources and administered according to prescribed orders for safety and legal reasons.
D. Explaining that medication can only be provided to clients ensures adherence to hospital policies and legal regulations. This action maintains professional boundaries and ensures that only those who are officially under care receive medication.
Correct Answer is B
Explanation
A. Re-lubricating the tubing and re-inserting it is unnecessary if the enema solution is not infusing; the primary issue is likely related to the tubing's position or the height of the container.
B. Inserting the tubing an additional three inches into the rectum ensures that it is positioned correctly for the solution to flow. If the tubing is not inserted far enough, the solution may not enter the rectum.
C. Raising the saline container higher is not needed since it is already six inches above the client’s body. The problem is more likely related to the tubing’s depth rather than the height of the container.
D. Instructing the client to take deep breaths does not affect the infusion of the enema solution. The solution's flow is influenced by the mechanics of the enema administration, not by the client’s breathing.
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