Nokea
A patient is scheduled for enucleation and the nurse is providing anticipatory guidance about postoperative care. What aspects of care should the nurse describe to the patient? Select all that apply.
- A. Application of topical antibiotic ointment
- B. Maintenance of a supine position for the first 48 hours postoperative
- C. Fluid restriction to prevent orbital edema
- D. Administration of loop diuretics to prevent orbital edema
- E. Use of an ocular pressure dressing
Correct Answer: A,E
Rationale: Post-enucleation care includes topical antibiotic ointment and an ocular pressure dressing to prevent infection and support healing. Supine positioning, fluid restriction, and diuretics are not indicated.
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A hospitalized patient with impaired vision must get a picture in his or her mind of the hospital room and its contents in order to mobilize independently and safely. What must the nurse monitor in the patients room?
- A. That a commode is always available at the bedside
- B. That all furniture remains in the same position
- C. That visitors do not leave items on the bedside table
- D. That the patients slippers stay under the bed
Correct Answer: B
Rationale: Consistent furniture placement reduces fall risk for visually impaired patients. Commodes, bedside table items, and slipper placement are secondary concerns.
A patients ocular tumor has necessitated enucleation and the patient will be fitted with a prosthesis. The nurse should address what nursing diagnosis when planning the patients discharge education?
- A. Disturbed body image
- B. Chronic pain
- C. Ineffective protection
- D. Unilateral neglect
Correct Answer: A
Rationale: Enucleation and prosthesis use significantly impact body image. Chronic pain, ineffective protection, and unilateral neglect are not typically associated with this procedure.
Several residents of a long-term care facility have developed signs and symptoms of viral conjunctivitis. What is the most appropriate action of the nurse who oversees care in the facility?
- A. Arrange for the administration of prophylactic antibiotics to unaffected residents.
- B. Instill normal saline into the eyes of affected residents two to three times daily.
- C. Swab the conjunctiva of unaffected residents for culture and sensitivity testing.
- D. Isolate affected residents from residents who have not developed conjunctivitis.
Correct Answer: D
Rationale: Isolating affected residents prevents the spread of viral conjunctivitis. Antibiotics, saline flushes, and swabbing unaffected residents are ineffective or unnecessary.
A patient with low vision has called the clinic and asked the nurse for help with acquiring some low-vision aids. What else can the nurse offer to help this patient manage his low vision?
- A. The patient uses OTC NSAIDs.
- B. The patient has a history of stroke.
- C. The patient has diabetes.
- D. The patient has Asian ancestry.
Correct Answer: C
Rationale: Diabetes is a risk factor for glaucoma, which can worsen low vision. The nurse can offer education on managing diabetes to protect vision. NSAIDs, stroke, and Asian ancestry are not directly relevant.
A patient has just arrived to the floor after an enucleation procedure following a workplace accident in which his left eye was irreparably damaged. Which of the following should the nurse prioritize during the patients immediate postoperative recovery?
- A. Teaching the patient about options for eye prostheses
- B. Teaching the patient to estimate depth and distance with the use of one eye
- C. Assessing and addressing the patients emotional needs
- D. Teaching the patient about his post-discharge medication regimen
Correct Answer: C
Rationale: Emotional support is critical after unexpected enucleation due to trauma. Teaching about prostheses, depth perception, or medications is important but secondary in the immediate postoperative period.