Friday 16 October 2020

Q. The nurse observes that the right eye of an unconscious client does not close completely. Which nursing intervention is most appropriate?

A. Have the client wear eyeglasses at all times.

B. Lightly tape the eyelid shut.

C. Instill artificial tears once every shift.

D. Clean the eyelid with a washcloth every shift.

Correct Answer: B

Reason: When the blink reflex is absent or the eyes do not close completely, the cornea may become dry and irritated. Corneal abrasion can occur. Taping the eye closed will prevent injury. Having the client wear eyeglasses or cleaning the eyelid will not protect the cornea from dryness or irritation. Artificial tears instilled once per shift are not frequent enough for preventing dryness.


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