Nokea
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.
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A client has been taught about retinitis pigmentosa (RP). What statement by the client indicates a need for further teaching?
- A. I should continue wearing sunglasses.
- B. Beta carotene, lutein, and zeaxanthin are good supplements.
- C. I may qualify for a retinal transplant one day soon.
- D. Vitamin A has been shown to slow progression of RP.
Correct Answer: C
Rationale: Retinal transplants are not a current or near-future treatment for retinitis pigmentosa. Sunglasses help protect against cataracts, and supplements like beta carotene, lutein, zeaxanthin, and vitamin A may slow RP progression.
A client is seen in the ophthalmology clinic with bacterial conjunctivitis. Which statements by the client indicate correct understanding? (Select all that apply.)
- A. I won't wipe my eyes with the same cloth and share my towel.
- B. Eye irrigation should be done with warm saline or water.
- C. I have been prescribed antibiotics for my infection.
- D. I won't touch the tip of the eyedrop bottle to my eye.
- E. When the infection is gone, I can wear my contacts again.
Correct Answer: C,D
Rationale: Bacterial conjunctivitis is very contagious, and re-infection or cross-contamination must be avoided. Not touching the eyedrop bottle tip to the eye and using prescribed antibiotics are correct actions. Sharing towels, improper irrigation, or premature contact lens use can worsen or spread the infection.
A client asks why blindness occurred from glaucoma. What explanation by the nurse is best?
- A. Because eye pressure was too high, the tissue died.
- B. Glaucoma always leads to permanent blindness.
- C. The traumatic damage to your eye was too great.
- D. The infection occurs so quickly, it can be treated.
Correct Answer: A
Rationale: Glaucoma is caused when the intraocular pressure becomes too high and stays high long enough to cause tissue ischemia and death. At that point, vision loss is permanent. Glaucoma does not always cause blindness, trauma is not the most common cause, and glaucoma is not an infection.
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.
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.