Nokea
A nurse is caring for a client who has undergone enucleation. What complication of enucleation should be addressed by the nurse?
- A. Hypotension
- B. Nausea and vomiting
- C. Hemorrhage
- D. Pneumonia
Correct Answer: C
Rationale: The nurse should take measures to prevent hemorrhage, a complication of enucleation, by applying a pressure dressing. Nausea and vomiting are common side effects of surgery. Enucleation does not increase risk of developing hypotension or pneumonia.
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A nurse is caring for a client newly diagnosed with glaucoma. Which would be a priority in the nurse's teaching about maintaining normal pressure range in the eye?
- A. Increase fiber in the diet.
- B. Avoid reading.
- C. Eat small meals.
- D. Treat allergy symptoms promptly.
Correct Answer: A
Rationale: Adding fiber to the diet will increase ease of bowel movements and prevent constipation and straining, which can inadvertently increase intraocular pressure. Eating small meals is insignificant in maintaining intraocular pressure. Avoid over-the-counter treatment of cold and allergy symptoms if contains cholinergic blockers. Reading is not significant in changing intraocular pressure, but eye strain should be avoided.
While cleaning gutters, a client reports getting debris in the eyes. On inspection, the nurse notes no obvious foreign object. Which diagnostic evaluation technique would be most beneficial for this client?
- A. Administer fluorescein dye.
- B. Obtain an x-ray for orbital fractures.
- C. Assess intraocular movements.
- D. Assess with tonometer.
Correct Answer: A
Rationale: Fluorescein dye stains the eye and helps to identify minute foreign body or abrasions in the cornea. X-ray of the eye orbit would be done if a blow to the area preceded the visit. Assessment of intraocular movements (cranial nerves III, IV, and VI) would not be indicated. Tonometry is done for assessment of intraocular pressure and would not be indicated.
A nurse is caring for a client immediately following cataract removal. Which symptom would be most alarming to the nurse?
- A. Irritation in the operative eye
- B. Dilation of the pupil
- C. Dry, tickling cough
- D. Fever
Correct Answer: C
Rationale: Coughing can rise the intraocular pressure and should be avoided. A cough suppressant can be prescribed. The pupil was intentionally dilated during the surgical approach and will resolve. The client may complain of mild eye irritation in the immediate postoperative period. Fever can be a complication of cataract surgery but not expected in the immediate period postoperatively.
A nurse is caring for a client who has just been diagnosed with glaucoma. What teaching should the nurse include with this client?
- A. How long it will be necessary to wear dark glasses
- B. The importance of regular bowel habits
- C. What vegetables to eat
- D. When it will be possible to read again
Correct Answer: B
Rationale: Instructions for the client with glaucoma include the following: Obtain assistance from a family member, relative, or friend if having trouble instilling eye drops. Avoid all drugs that contain atropine. Check with physician or pharmacist before using any nonprescription drug. preparations for cold or allergy symptoms may contain an atropine-like drug. Maintain regular bowel habits; straining at stool can raise intraocular pressure (IOP). Avoid heavy lifting and emotional upsets (especially crying) because they increase IOP. Patients do not have to wear dark glasses. Vegetable consumption is not restricted. Reading does not increase IOP.
A nurse is caring for a client who has exhibited repeated return of hordeolum (sty). Which assessment finding is most important in determining care for this client?
- A. Dabbing the eyes multiple times with a washcloth
- B. Presence of low blood sugar
- C. Use of disposable wash cloths
- D. Use of antibacterial facial wash
Correct Answer: A
Rationale: Hordeolum is an infection usually caused by Staphylococcus aureus. To avoid transferring microorganisms, the client should not dab the eyes multiple times with a washcloth but should instead clean the unaffected eye first and change the washcloth, towel, and water after contact with the affected eye. The nurse should also instruct the client to use separate fresh tissues, cotton balls, or gauze for each wiping stroke when cleaning exudate from the eye. Clients with high blood sugar are more likely to develop hordeolum. Use of disposable wash cloths, antibacterial cleansers, and good hygiene practices are preventable techniques.