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A nurse is preparing to assess a client’s conjunctiva.
Identify the sequence the nurse should follow when taking the following actions.
1) Apply examination gloves.
2) Instruct the client to look up.
3) Place the thumbs below each of the client’s lower eyelids.
4) Gently pull the client’s skin down to the top edge of the bony orbital rim.
5) Inspect the color and condition of the conductive and sclera, noting any color change, swelling, drainage, or lesions.
The nurse should follow the sequence of 1, 2, 3, 4, 5 when assessing the client’s conjunctiva. This is because the nurse should first apply examination gloves to prevent contamination and infection. Then, the nurse should instruct the client to look up to expose the lower eyelid and conjunctiva. Next, the nurse should place the thumbs below each of the client’s lower eyelids and gently pull the skin down to the top edge of the bony orbital rim. This allows the nurse to inspect the color and condition of the conjunctiva and sclera, noting any color change, swelling, drainage, or lesions. The sclera should be white and the conjunctiva should be pink.
The nurse should not pull down the skin before instructing the client to look up. This could cause discomfort and injury to the eye.
The nurse should not instruct the client to look up after pulling down the skin. This could also cause discomfort and injury to the eye.
The nurse should not place the thumbs below each of the client’s lower eyelids before applying examination gloves.
This could introduce infection and irritants to the eye.
The nurse should follow the sequence of 1, 2, 3, 4, 5 when assessing the client’s conjunctiva. This is because the nurse should first apply examination gloves to prevent contamination and infection. Then, the nurse should instruct the client to look up to expose the lower eyelid and conjunctiva. Next, the nurse should place the thumbs below each of the client’s lower eyelids and gently pull the skin down to the top edge of the bony orbital rim. This allows the nurse to inspect the color and condition of the conjunctiva and sclera, noting any color change, swelling, drainage, or lesions. The sclera should be white and the conjunctiva should be pink.
Choice B is wrong because the nurse should not pull down the skin before instructing the client to look up.
This could cause discomfort and injury to the eye.
Choice C is wrong because the nurse should not instruct the client to look up after pulling down the skin.
This could also cause discomfort and injury to the eye.
Choice D is wrong because the nurse should not place the thumbs below each of the client’s lower eyelids before applying examination gloves.
This could introduce infection and irritants to the eye.