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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.
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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.
Which actions by the unlicensed assistive personnel (UAP) warrant intervention by the nurse? (Select all that apply.)
- A. Holding the wet washcloth in the microwave
- B. Holding the cloth on the client using an Ace wrap
- C. Turning the cloth so it remains warm on the client
- D. Using a clean washcloth for the compress
- E. Washing the hands on entering the clients room
Correct Answer: A,B
Rationale: The washcloth should be warmed under running warm water, as microwaving it can lead to burns. Gentle pressure is used to hold the compress in place, not an Ace wrap. The other actions are correct.
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.
The nurse working in the ophthalmology clinic sees clients with eyelid and eye problems. What information should the nurse understand about these disorders? (Select all that apply.)
- A. A chalazion is an inflammation of an eyelid sebaceous gland.
- B. An ectropion is the eyelid turning outward.
- C. An entropion is the eyelid turning outward.
- D. A hordeolum is an infection of the eyelid sweat gland.
- E. Keratoconjunctivitis sicca is caused by drugs or diseases.
Correct Answer: A,D,E
Rationale: A chalazion is an inflammation of one of the sebaceous glands in the eyelid. A hordeolum is an infection of a sweat gland in the eyelid. Keratoconjunctivitis sicca can be caused by drugs or diseases. An ectropion is an outward turning and sagging eyelid, while an entropion is an inward turning of the eyelid.
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.