Author Question: During a bed bath a client complains of drainage from the eye. What would be the best rationale for ... (Read 40 times)

sarasara · **on:** Jul 17, 2018

During a bed bath a client complains of drainage from the eye. What would be the best rationale for using separate supplies for each eye?

A) Protect the tear ducts
B) Avoid damage to sensitive eye tissues
C) Help to prevent spreading infection between the eyes
D) Move debris away from each eye

Question 2

A client is brought to the community health clinic after he was rescued from a burning building. The client has minor burns on 20 of his head and neck. What is the priority nursing intervention for this client?

A) Dress the burns with salve.
B) Wrap the burns with sterile bandages.
C) Monitor the client's respiratory status.
D) Insert a feeding tube before edema sets in.

hramirez205 · **Reply #1 on:** Jul 17, 2018

Answer to Question 1

C
Feedback:
It is important to use separate supplies for each eye. This helps to prevent spreading infection between the eyes. The nurse should moisten a clean washcloth and cleanse from the inner canthus to the outer so as to move debris away from the eye, prevent reinfection or contamination of the eye, and protect the tear ducts. The eye area should be washed before, not after, washing any other part of the body to avoid introducing harmful microorganisms into the sensitive eye tissues. The nurse should wipe the client's eyelid with cotton balls soaked in sterile water or normal saline, if ordered, and not with antiseptic solution to avoid damage to the sensitive eye tissues.

Answer to Question 2

C
Feedback:
Smoke inhalation is often the cause of death for clients who do not have noticeable external burns. The nurse should carefully monitor the client's respiratory status, including the rate and depth of respirations. Individuals who have head and neck area burns should especially be monitored closely because such individuals are more likely to have respiratory damage. Salve should not be placed on the burns and a feeding tube would not be inserted unless deemed necessary. Burns may be wrapped, but this is not the priority intervention for this client.