Nokea
The client with cataracts who has had intraocular lens implants is being discharged from the day surgery department. Which discharge instructions should the nurse discuss with the client?
- A. Do not push or pull objects heavier than 50 pounds.
- B. Lie on the affected eye with two pillows at night.
- C. Wear glasses or metal eye shields at all times.
- D. Bend and stoop carefully for the rest of your life.
Correct Answer: C
Rationale: Wearing eye shields protects the eye post-cataract surgery, especially at night. Heavy lifting is restricted lighter, lying on the affected eye is avoided, and lifelong bending restrictions are excessive.
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A 10-year-old boy comes to the school clinic holding his broken pair of glasses. He says that he got hit in the face playing ball and his eye hurts and feels like there's something in it. What should the nurse do before taking him to the emergency room?
- A. Thoroughly examine his eyes
- B. Put a pressure dressing on his right eye.
- C. Cover both eyes lightly with gauze
- D. Flush his right eye with water for 20 minutes
Correct Answer: C
Rationale: Covering both eyes lightly with gauze prevents tracking and further injury, suitable for a suspected foreign body until emergency evaluation.
The client tells the nurse, 'I have something under my upper eyelid and don't recall how it happened.' The client has no eye redness or pain and no changes in vision. Which intervention should the nurse implement?
- A. Notify the client's health care provider for guidance.
- B. Flush the client's eye with sterile saline for 10 minutes.
- C. Evert the upper lid with a cotton-tipped applicator for examination.
- D. Place an eye patch, taping from the outside of the eye to the inside.
Correct Answer: C
Rationale: Since the client has no pain or vision changes, the nurse should assess by everting the upper eyelid with a cotton-tipped applicator to visualize the issue. Contacting the HCP, flushing, or patching should follow assessment.
The charge nurse is admitting a 90-year-old client to a long-term care facility. Which intervention should the nurse implement?
- A. Ensure the client's room temperature is cool.
- B. Talk louder to make sure the client hears clearly.
- C. Complete the admission as fast as possible.
- D. Provide extra orientation to the surroundings.
Correct Answer: D
Rationale: Extra orientation helps elderly clients with sensory deficits adjust to new environments, enhancing safety. Cool rooms, loud talking, and rushed admissions are less effective.
An older woman has had a CVA. The nurse notes that she seems to be unaware of objects on her right side (right homonymous hemianopia). Which nursing action is most important in planning to assist her to compensate for this loss?
- A. Place frequently used items on the affected side
- B. Position her so that her affected side is toward the activity in the room
- C. Encourage her to turn her head from side to side to scan the environment on the affected side
- D. Stand on the affected side while assisting her in ambulating
Correct Answer: C
Rationale: Encouraging head turning to scan the environment compensates for right homonymous hemianopia by ensuring awareness of the affected side.
The nurse is teaching the client with open-angle glaucoma. Which instruction should the nurse include?
- A. Limit oral fluid intake to 1000 mL daily.
- B. Eat foods that are high in omega-3 fatty acids.
- C. Have annual eye exams with an eye specialist.
- D. Use timolol maleate eye drops when feeling eye pressure.
Correct Answer: C
Rationale: Glaucoma is a chronic progressive disease; annual eye examinations should be completed by an eye specialist physician. Fluid restriction and omega-3 fatty acids do not affect intraocular pressure. Elevated intraocular pressure cannot be felt, and timolol maleate should be used as prescribed.