Question 1

The patient is brought into the emergency department after a motor vehicle accident.The patient is unresponsive.The nurse is concerned about whether or not the patient wears contact lenses because contact lenses that are not removed can cause _______________.

Accepted Answer

corneal injury
It is extremely important to determine whether patients wear contact lenses,particularly when patients are admitted to hospitals or agencies in an unresponsive or confused state.If a seriously ill patient is wearing contact lenses,and this fact goes undetected,severe corneal injury can result.

Question 2

When providing eye care for the comatose patient,the nurse should:
A)place the patient in a prone position for easier access.
B)use a different corner of the washcloth for each eye.
C)wipe each eye from outer to inner canthus.
D)use a sterile medicine cup to instill lubricant.

Accepted Answer

Use a separate,clean cotton ball or corner of the washcloth for each eye.Place the patient in supine position.Gently wipe each eye from inner to outer canthus.Use an eyedropper to instill the prescribed lubricant (e.g. ,saline,methylcellulose,and liquid tears)as ordered.

Question 3

The patient is brought to the emergency department after receiving a chemical burn to his eyes.The doctor orders immediate eye irrigations.Of the following solutions,which would be the most beneficial for this patient?
A)Lactated Ringer's solution
B)Albumin
C)Tap water
D)Dextrose and water

Accepted Answer

Controversy continues over the best solution for irrigating the eye in a health care setting.When a choice of normal intravenous (IV)solutions is available,lactated Ringer's solution is more effective than normal saline in restoring pH after a chemical burn to the eye.Often cool tap water is recommended for emergency eye flushing because it is effective and immediately available for first aid.Dextrose and water,and albumin usually are not used for eye irrigation.

Question 4

Which of the following nursing interventions would the nurse perform first after a patient sustained a chemical splash injury to the eye?
A)Assess visual acuity.
B)Flush the eye with large amounts of irrigation fluid.
C)Assess level of pain.
D)Determine whether the pupils are equal,round,reactive to light and accommodation (PERRLA).

Accepted Answer

The first thing the nurse should do when caring for a patient who has sustained a chemical injury to the eye is flush the eye with large amounts of irrigation fluid.Assessing visual acuity,pain,and PERRLA will be performed after the eye has been irrigated appropriately.

Question 5

When instructing a patient on correct technique for inserting a hearing aid into the ear,the nurse will include which of the following instructions?
A)Pull the outer ear up and out.
B)Hold the aid with the long portion upright.
C)Fit the aid snugly in the midline of the canal.
D)Turn the aid to the desired sound level before insertion.

Accepted Answer

Hold the hearing aid in the dominant hand and insert the pointed end of the ear mold into the ear canal while following the natural contours of the canal.Pulling up and out on the outer ear has little effect on hearing aid insertion.Instead,hold the hearing aid in the dominant hand and insert the pointed end of the ear mold into the ear canal while following the natural contours of the canal.Turn the volume slowly to high to prevent damage to the hearing aid.

Question 6

The patient is found to have impacted cerumen in his ear canal.The nurse most likely will:
A)instill 1 to 2 drops of mineral oil.
B)instill the irrigation under pressure.
C)occlude the ear canal when irrigating.
D)straighten the ear canal.

Accepted Answer

If the patient is found to have impacted cerumen,instill 1 to 2 drops of mineral oil or over-the-counter softener into the ear twice a day for 2 to 3 days before irrigation,to loosen cerumen and ensure easier removal during irrigation.The greatest danger during administration of ear irrigation is rupture of the tympanic membrane.Fluids must not be instilled under pressure or with the irrigating device occluding the ear canal.Always attempt to remove foreign objects in the ear by first simply straightening the ear canal.Cerumen,however,is wax buildup and is not a foreign object.

Question 7

When removing a soft contact lens,the nurse finds that it is sticking together.What should the nurse do next?
A)Rub the lens briskly.
B)Soak the lens in saline.
C)Place cleansing solution on the lens.
D)Pry the lens apart with the fingertips.

Accepted Answer

If the lens edges stick together,place the lens in the palm and soak thoroughly in saline;gently roll the lens back and forth with the index finger.If this is unsuccessful in restoring the shape of the lens,placing the lens in cleansing solution would be the next step.Brisk rubbing may damage the lens.Prying the lens apart could damage it.

Question 8

The nurse caring for a comatose patient determines that he is wearing contact lenses.Which of the following nursing interventions will the nurse use when removing the contact lenses?
A)Put on snug,powdered,clean gloves.
B)Ask the patient to look down to expose the lower eyeball.
C)Use the fingernail to slide the lens off of the cornea.
D)Inspect the eye after the lenses have been removed.

Accepted Answer

After the lenses have been removed,inspect the eye for redness,pain,swelling of the eyelids or conjunctivae,discharge,or excess tearing.Perform hand hygiene.Don snug,powder-free,clean gloves,and place a towel just below the patient's face.Ask the patient to look up to expose the lower eyeball to which the lens will be displaced.With the pad of the index finger of the same hand,slide the lens off the cornea down onto the lower sclera.Use of the pad rather than the fingernail prevents injury to the cornea and damage to the lens.

Question 9

A _____________ is a small,battery-powered,electronic device that amplifies sound.

Accepted Answer

The answer of A _____________ is a small,battery-powered,electronic device that...

Question 10

The nurse is preparing to clean the patient's hearing aid.The nurse realizes that she must:
A)make sure the hearing aid volume is turned on before removing the hearing aid.
B)hold the hearing aid over the sink when cleansing.
C)insert a paper clip into the receiver port to cleanse cerumen buildup.
D)make sure the pressure equalization channel is clear.

Accepted Answer

The pressure equalization channel is a tiny hole through the entire length of the ear mold;it should be clear for the entire length.Before removing the hearing aid,turn the volume off to prevent feedback (whistling)during removal.Hold the hearing aid over a towel,and wipe the exterior with tissue to remove the cerumen.This prevents breakage if dropped.The receiver port is easily damaged.Never insert anything into the receiver port.

Question 11

The elderly patient is instructed to store his hearing aid in a(n):
A)cold place.
B)container that keeps out moisture.
C)easy to reach place.
D)a cup of water.

Accepted Answer

Hearing aids and batteries should be stored in a dry container with desiccant or in an electronic dryer to prolong life,minimize repairs,and preserve batteries.Advise the patient to avoid exposing the hearing aid to extremes of temperature.Batteries are toxic if swallowed;keep them away from pets and children.Advise the patient to protect the hearing aid from water,alcohol,hair spray or cologne,perspiration,rain,and snow.

Question 12

The substance found in the ear canal that has an antibacterial effect and maintains an acid pH is called ______________.

Accepted Answer

The answer of The substance found in the ear canal...

Question 13

How should the nurse position the ear when performing ear irrigation for a 2-year-old patient?
A)Instill the irrigating solution quickly and forcefully.
B)Pull the pinna up and back.
C)Direct the fluid toward the anterior aspect of the ear canal.
D)Pull the pinna down and back.

Accepted Answer

In children age 3 or younger,pull the pinna down and back.Slowly instill irrigating solution by holding the tip of the syringe 1 cm (0.39 inch)above the opening to the ear canal.Allow fluid to drain out during instillation into the basin.Continue until the canal is cleansed or the solution is used.Slow instillation prevents buildup of pressure in the ear canal and ensures contact of the solution with all canal surfaces.For adults and children older than age 3,gently pull the pinna up and back.Direct the fluid toward the superior aspect of the ear canal.

Question 14

How does the nurse assess that a hearing aid is operating correctly?
A)Speaking very softly behind the patient
B)Covering the patient's unaffected ear and speaking
C)Determining the patient's response to a normal tone of voice
D)Removing the hearing aid and sending it to be checked by an audiologist

Accepted Answer

To determine whether the patient can hear clearly using the hearing aid,turn your back to the patient and ask a question slowly and clearly in a normal tone of voice.Depending on your position,the patient may be able to read your lips.The prostheses are limited by the function of the ear structures.The hearing aid may not be the problem in this case.

Question 15

The nurse decides that assistive personnel can provide care to a patient with contact lenses when the assistive personnel states:
A)"If I am in a hurry,I will use tap water for rinsing the lenses."
B)"Gloves aren't necessary;the eye is a clean organ."
C)"I will check with the patient to see if the lenses are disposable."
D)"It is normal for contact lens wearers to have red,teary eyes."

Accepted Answer

Let the patient be a resource in the care of each device.Although it is the nurse's responsibility to ensure that patients do not damage their devices or injure themselves,patients familiar with their devices are likely to have an established routine and helpful tips.The replacement schedule is determined by the type of lenses the patient wears;the patient can provide that information.Tap water can contain microorganisms and may be absorbed into the lens,making it uncomfortable to wear.Clean,powder-free gloves are used to prevent the spread of microorganisms during care of contact lenses.Pain,tearing,discomfort,and redness can indicate conjunctivitis and should be referred to the patient's provider if symptoms persist.

Question 16

When providing care to a patient who has splashed bleach into his eye,the nurse will:
A)remove the patient's contacts immediately.
B)flush the eye from the outer to the inner canthus.
C)reinsert contacts as soon as irrigation is done.
D)irrigate toward the lower conjunctival sac.

Accepted Answer

Ask the patient to look toward the brow.Gently irrigate with a steady stream toward the lower conjunctival sac.This will minimize the force of the stream on the cornea and will flush irritant out of the eye and away from the other eye and nasolacrimal duct.In an emergency such as first aid for a chemical burn,do not delay flushing by removing the patient's contact lens before irrigation.Do not remove the contact unless rapid swelling is occurring.Flush the eye from the inner to the outer canthus.Advise the patient to consult the prescriber before reusing the contact lens.

Question 17

The nurse is preparing to provide eye care for a comatose patient.The nurse realizes that comatose patients do not have natural protective mechanisms to protect the cornea.These protective mechanisms include: (Select all that apply. )
A)blinking.
B)squinting.
C)lubrication.
D)dilation.

Accepted Answer

Comatose patients do not have the natural protective mechanisms to protect the cornea.These protective mechanisms include blinking and lubrication of the eye.When patients are in a coma,the nurse is responsible for providing this care.

Question 18

In caring for a patient with contact lenses,the nurse should be aware that:
A)rigid gas-permeable (RGP)lenses are no longer used.
B)soft contact lenses are smaller than the cornea.
C)all lenses must be removed periodically.
D)extended wear lenses can be used for only 6 nights.

Accepted Answer

It is important to remember that all lenses must be removed periodically to prevent infection and corneal damage,and that proper cleaning is necessary before a lens is reinserted.Two basic types of contact lenses are used today: RGP and soft.Rigid contact lenses are made of firm,durable plastic and are smaller than the cornea.Soft contact lenses are made of a flexible hydrogel plastic and cover the entire cornea and a small rim of the sclera.Although the limit for extended wear lenses is usually 6 nights,certain soft lenses have been approved for continuous wear up to 30 nights.

Quiz 19: Care of the Eye and Ear

The patient is brought into the emergency department after a motor vehicle accident.The patient is unresponsive.The nurse is concerned about whether or not the patient wears contact lenses because contact lenses that are not removed can cause _______________.

When providing eye care for the comatose patient,the nurse should:

The patient is brought to the emergency department after receiving a chemical burn to his eyes.The doctor orders immediate eye irrigations.Of the following solutions,which would be the most beneficial for this patient?

Which of the following nursing interventions would the nurse perform first after a patient sustained a chemical splash injury to the eye?

When instructing a patient on correct technique for inserting a hearing aid into the ear,the nurse will include which of the following instructions?

The patient is found to have impacted cerumen in his ear canal.The nurse most likely will:

When removing a soft contact lens,the nurse finds that it is sticking together.What should the nurse do next?

The nurse caring for a comatose patient determines that he is wearing contact lenses.Which of the following nursing interventions will the nurse use when removing the contact lenses?

A _____________ is a small,battery-powered,electronic device that amplifies sound.

The nurse is preparing to clean the patient's hearing aid.The nurse realizes that she must:

The elderly patient is instructed to store his hearing aid in a(n) :

The substance found in the ear canal that has an antibacterial effect and maintains an acid pH is called ______________.

How should the nurse position the ear when performing ear irrigation for a 2-year-old patient?

How does the nurse assess that a hearing aid is operating correctly?

The nurse decides that assistive personnel can provide care to a patient with contact lenses when the assistive personnel states:

When providing care to a patient who has splashed bleach into his eye,the nurse will:

The nurse is preparing to provide eye care for a comatose patient.The nurse realizes that comatose patients do not have natural protective mechanisms to protect the cornea.These protective mechanisms include: (Select all that apply. )

In caring for a patient with contact lenses,the nurse should be aware that: