# A nurse is caring for a client who presents to the emergency department with a metal fragment embedded in the right eye following a workplace accident. What is the most appropriate initial nursing intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541614 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client who presents to the emergency department with a metal fragment embedded in the right eye following a workplace accident. What is the most appropriate initial nursing intervention? ## 보기 1. Remove the metal fragment immediately to prevent further damage 2. Irrigate the eye with normal saline to flush out debris 3. Cover both eyes with protective shields and keep the client in a supine position **✔ 정답** 4. Apply direct pressure around the embedded object to control bleeding **정답: 3** ## 해설 The priority is to prevent further damage by stabilizing the object and protecting both eyes from movement. Covering both eyes prevents consensual eye movement that could displace the fragment, while removing, irrigating, or applying pressure could worsen the injury. ## 심화 해설 Understanding the Priority: Preventing Further Injury When a client presents with a penetrating ocular injury involving a retained metal fragment, the primary goal of the initial nursing intervention is to prevent further damage to the eye. The visual outcome of such trauma is significantly influenced by the extent of the initial damage and the timeliness of specialized care . Any manipulation of the eye or the embedded object by a non-ophthalmologist can exacerbate the injury, leading to worse outcomes, including permanent monocular blindness . Analysis of the Correct Answer (Option 3) Covering both eyes with protective shields is the most appropriate initial action. This intervention works through a critical physiological mechanism: consensual eye movement. When one eye moves, the other eye instinctively moves in tandem. If only the injured eye were covered, the unaffected eye would still move to scan the environment, causing the injured eye to move simultaneously. This movement can cause the embedded metal fragment to lacerate intraocular structures further, increasing the extent of damage and worsening the visual prognosis . By covering both eyes, all eye movement is minimized. Keeping the client in a supine position further aids in immobilization and reduces intraocular pressure fluctuations that could occur with movement. Why Other Options Are Incorrect - Option 1: Remove the metal fragment immediately. This is strictly contraindicated. Removal of a penetrating foreign body is a complex surgical procedure that must be performed by an ophthalmologist under controlled conditions. Premature removal in the emergency department can cause prolapse of intraocular contents (like the vitreous humor or iris), uncontrolled bleeding, and further structural damage, directly compromising the potential for visual recovery . - Option 2: Irrigate the eye with normal saline. Irrigation is the first-line treatment for chemical burns or superficial foreign bodies. However, in the case of a penetrating injury with a retained object, irrigation can introduce fluid into the globe, increasing intraocular pressure, dislodging the fragment, or introducing infection. The mechanism of injury here is a high-velocity metal fragment, which has already penetrated the globe, making irrigation dangerous and ineffective. - Option 4: Apply direct pressure around the embedded object. Applying any pressure to a globe with a penetrating injury is dangerous. Direct pressure can expel intraocular contents through the wound, leading to catastrophic and irreversible vision loss. The principle of managing a penetrating eye injury is to avoid any pressure on the globe itself, which is why protective shields, not pressure dressings, are used. The clinical profile of penetrating ocular injuries demonstrates that the mechanism and type of injury are key determinants of the final visual outcome . The nurse’s role is to stabilize the injury exactly as it is, preventing a closed-globe injury from becoming a more severe open-globe rupture through inadvertent movement or pressure, thereby preserving the client's best chance for recovery. ## 임상 시나리오 Clinical Scenario A 34-year-old construction worker presents to the emergency department after a metal-on-metal hammering incident. A metallic foreign body is visibly protruding from the right cornea. The client reports severe pain, photophobia, and a sensation of something in the eye. Visual acuity in the affected eye is limited to light perception. Nursing Assessment - Mechanism of injury: High-velocity metal fragment (risk for open globe injury). - Visual inspection: Do not palpate or exert pressure on the globe. Note size, location, and depth of the protruding object without manipulation. - Pain assessment: Severe, sharp pain rated 8/10. - Check tetanus immunization status. Immediate Nursing Interventions - **Immobilize both eyes:** Apply a rigid protective shield (e.g., Fox shield) over the injured eye. Do not use a gauze patch which can apply pressure. Then, cover the unaffected eye with a shield or patch to eliminate consensual eye movement. - **Positioning:** Maintain the client in a supine position with the head of the bed elevated approximately 30 degrees to minimize intraocular pressure. - **Strict NPO status:** Anticipate emergency surgical repair under general anesthesia. - **Administer medications as prescribed:** Systemic analgesics, broad-spectrum intravenous antibiotics, and antiemetics to prevent Valsalva maneuver from vomiting. - **Psychosocial support:** Provide reassurance and explain the rationale for bilateral eye patching to reduce anxiety and prevent the client from instinctively trying to remove the shield. Critical Safety Alerts - **Never attempt to remove the foreign body.** - **Never irrigate the eye.** - **Never apply direct pressure or ointment to the eye.** - These actions are reserved for the ophthalmologist in a controlled surgical setting and can result in permanent vision loss if performed prematurely. ## 핵심 개념 - **Consensual eye movement** — The involuntary, simultaneous movement of both eyes in the same direction; covering both eyes immobilizes the injured eye by preventing this reflex. - **Penetrating ocular injury** — A wound that enters the cornea or sclera, often involving a retained foreign body, requiring emergency management to prevent vision loss. - **Protective eye shield** — A rigid device placed over the eye to protect it from pressure or further trauma without making direct contact with the globe. ## 같은 주제 문제 - [A 28-year-old construction worker presents to the emergency department with a penetrating …](https://mymerci.kr/pages/nclex_q.php?qn_id=541611) - [A nurse is caring for a client who presents to the emergency department with a metal fragm…](https://mymerci.kr/pages/nclex_q.php?qn_id=541612) - [A nurse is caring for a client who sustained a penetrating eye injury from a metal fragmen…](https://mymerci.kr/pages/nclex_q.php?qn_id=541613) - [A nurse is caring for a client who presents to the emergency department with a metal fragm…](https://mymerci.kr/pages/nclex_q.php?qn_id=541615) - [A nurse is caring for a client who presents to the emergency department with a metal fragm…](https://mymerci.kr/pages/nclex_q.php?qn_id=541616) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._