TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER
Chapter 12: Care of the Eye and Ear Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse prepares to remove the patient’s soft contact lenses. Which intervention does the
nurse implement to remove the lenses without traumatizing the cornea? a. Irrigate the eye with 50 mL of a sterile saline solution. b. Pull the lid down and instruct the patient to blink. c. Pinch the sides of the lens together and pop it out. d. Move the lens to the sclera and compress the lens gently. ANS: D
To remove a soft contact lens from a patient’s eye, the nurse moves the lens to the sclera and gently compresses it. This maneuver disrupts the surface tension holding the lens to the eye, allowing the nurse to lift the lens off the eye without traumatizing the cornea. The nurse avoids flooding the eye with irrigation solution because it increases the risk of losing the lens. The nurse asks the patient to blink to eject a hard lens. The nurse avoids pinching the lens since that would risk corneal trauma. DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning
OBJ: NCLEX: Physiological Integrity
2. The nurse irrigates the patient’s eye after the patient splashes an irritating liquid into it. Which
intervention does the nurse implement to prevent injury during eye irrigation? a. Positions the patient in high-Fowler’s position during the procedure. N b. Prevents the tip of the irrigating system from contacting the eyeball. c. Reassures the patient that the eye cannot be closed during irrigation. d. Allows the irrigating solution to run from the outer to the inner canthus. ANS: B
The nurse prevents additional injury to the patient’s eye during the eye irrigation by maintaining the irrigation system tip away from the eye. The nurse positions the patient in the side-lying position on the side of the affected eye to control the flow of irrigation solution. The patient is allowed to blink periodically during the irrigation. The nurse directs the irrigation solution to flow from the inner to the outer canthus to prevent contamination of the eye from a contaminated area. DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation
OBJ: NCLEX: Safe and Effective Care Environment
3. The nurse and the patient discuss the patient’s need for a hearing aid. What information does
the nurse include in patient teaching? a. An in-the-ear hearing aid is easy to manipulate. b. The patient’s specific needs and abilities are determining factors. c. The choice of a hearing aid is basically a financial matter. d. Behind-the-ear models are inferior to the other types. ANS: B
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