Nokea
The nurse is caring for a client who underwent surgery for a retinal detachment. The surgery included the injection of an air bubble to promote contact between the retina and choroids. What position should the nurse keep the client in?
- A. With the face parallel to the floor
- B. With the client's head slightly elevated
- C. With the client lying in a high Fowler's position
- D. With the client in an upright position
Correct Answer: A
Rationale: If an air bubble is instilled to promote contact between the retina and sclera, the client is positioned with the face parallel to the floor so that the bubble floats to the posterior of the eye. The client is asked to be on complete bed rest for several days with the head immobilized and to avoid any physical movements.
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A nurse is doing preoperative and postoperative teaching with a client who is undergoing cataract surgery. What is an important teaching point the nurse should emphasize to the client?
- A. Prepare for possible feelings of depression.
- B. Expect increased urine output.
- C. Eat soft, easily chewed food until healing is complete.
- D. Anticipate development of a periorbital hematoma.
Correct Answer: C
Rationale: Advise clients who have had cataract surgery to eat soft, easily chewed foods until healing is complete to avoid tearing from excessive facial movements. Clients who undergo cataract surgery do not become depressed, have increased urine output, or develop a periorbital hematoma.
A client with chronic open-angle glaucoma is now presenting with eye pain and intraocular pressure of 50 mm Hg. An immediate iridotomy is scheduled. Which explanation by the nurse describes the desired effects of this procedure?
- A. Reverse optic nerve damage
- B. Restore vision
- C. Improve outflow drainage
- D. To relieve pain
Correct Answer: C
Rationale: Laser iridotomy or standard iridotomy is a surgical procedure that provides additional outlet drainage of aqueous humor. This is done to lower the IOP as quickly as possible since permanent vision loss can occur in 1 to 2 days. Once optic nerve damage occurs, it cannot be reversed, and vision is not restored. Pain that occurs with rising IOP will be controlled once pressure is lowered through improved outflow drainage.
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.
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.
Which technique would be most beneficial for ambulation of a client who is visually impaired?
- A. Speak before touching the client.
- B. Provide a detailed description of the room and walkway.
- C. Allow client to follow the nurse's lead.
- D. Provide the client with a guide dog.
Correct Answer: C
Rationale: A blind person feels more secure and safe when assisted by someone who is sighted. The nurse should walk slightly ahead while allowing the client to hold onto the nurse's upper arm or elbow. Speaking before touching is an important care action in dealing with clients who have impaired vision but does not assist in ambulation. Providing a detailed description of the room may allow the client an image of the surroundings but is not as helpful in initial ambulation. Finding a perfect fit between guide dog and client is a lengthy process and should be pursued upon request of client.