Nokea
A client has a foreign body in the eye. What action by the nurse takes priority?
- A. Administering ordered antibiotics
- B. Assessing visual acuity in the affected eye
- C. Obtaining consent for immediate enucleation
- D. Removing the object immediately
Correct Answer: A
Rationale: To prevent infection, antibiotics are provided. Visual acuity in the affected eye cannot be assessed with a foreign body present. Enucleation is not typically required, and only an ophthalmologist should remove the foreign body.
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A client use a corneal ulcer. What information provided by the client most indicates a potential barrier to home care?
- A. Chronic use of sleeping pills
- B. Impaired near vision
- C. Slightly shaking hands
- D. Use of contact lenses
Correct Answer: A
Rationale: Antibiotic eyedrops are often needed every hour for the first 24 hours for corneal ulceration. The client who uses sleeping pills may not wake up each hour or may awaken unable to perform this task. Impaired near vision and shaking hands can both make administration of eyedrops more difficult but are not the most likely barriers. Contact lenses should be discarded.
A nurse is seeing clients in the ophthalmology clinic. Which client should the nurse see first?
- A. Client with intraocular pressure reading of 24 mm Hg
- B. Client who has had cataract surgery and has worsening vision
- C. Client whose red reflex is absent on ophthalmologic examination
- D. Client with a tearing, reddened eye with exudate.
Correct Answer: B
Rationale: Worsening vision after cataract surgery indicates a potential infection or other complication, which requires urgent attention. An intraocular pressure of 24 mm Hg is slightly elevated, an absent red reflex may indicate cataracts, and a tearing eye may suggest an infection but is less urgent.
A client had a retinal detachment and has undergone surgical correction. What discharge instruction is most important?
- A. Avoid reading, writing, or close work.
- B. Blind the lights in your house for at least a work.
- C. Keep the follow-up appointment with the ophthalmologist.
- D. Remove the eye patch to instill eyedrops.
Correct Answer: A
Rationale: After surgery for retinal detachment, the client is advised to avoid reading, writing, and close work because they cause rapid eye movements that could disrupt healing. Dim lights are not indicated, keeping postoperative appointments is important but not specific to retinal detachment, and the eye patch is not removed for eyedrops.
A client is brought to the emergency department after a car crash. The client has a large piece of glass in the left eye. What action by the nurse takes priority?
- A. Administer a tetanus booster shot.
- B. Ensure a patent airway.
- C. Prepare to irrigate the client's eye.
- D. Turn the client on the unaffected side.
Correct Answer: B
Rationale: Airway always comes first in emergency care. After ensuring a patent airway and providing cervical spine precautions, other care such as administering a tetanus booster shot may be considered. The eye should not be irrigated with a foreign body present.
A client is taking timolol (Timoptic) eyedrops. The nurse assesses the clients pulse at 50 beats/min. What action by the nurse is best?
- A. Administer the eyedrops as ordered.
- B. Assess the client for excessive salivation.
- C. Assess the client for shortness of breath.
- D. Hold the eyedrops and notify the provider.
Correct Answer: D
Rationale: Timolol is a beta blocker that can slow the heart rate. A pulse of 50 beats/min warrants holding the eyedrops and notifying the provider. Excessive salivation and shortness of breath are not typically related to timolol.