Basic Care and Comfort NCLEX PN Questions Nursing Practice Question
The client who has bilateral hand burns reports wearing soft contact lenses that need to be removed. Which action(s) are important for the nurse to include in this procedure? Select all that apply.
Correct Answer: A,C,E
Rationale: Ensuring proper hand hygiene and wearing gloves (A) is essential to prevent infection, especially when dealing with a client who has burns. Placing the lens in a sterile container with normal saline (C) maintains sterility and prepares for safe storage or disposal. Instructing the client to look up (E) helps facilitate lens removal by allowing better access to the eye.
Pinching the lens over the pupil (B) is inappropriate as it risks damaging the cornea or lens. Irrigating the eye with normal saline (D) is unnecessary for lens removal and may cause irritation or discomfort.