Nokea
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.
You may also like to solve these questions
An older client has decided to give up driving due to cataracts. What assessment information is most important to collect?
- A. Family history of visual problems
- B. Impact on daily activities
- C. History of falls
- D. Access to transportation
Correct Answer: B
Rationale: Cataracts can significantly impair vision, affecting the client's ability to perform daily activities safely. Assessing the impact on daily activities is critical to understanding the client's needs and planning appropriate interventions. Family history, falls, and transportation access are relevant but secondary to the immediate impact on daily functioning.
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 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.
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.