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The nurse will advise the patient to take which action following a left vitrectomy?
- A. Remain flat in bed for 48 hours.
- B. Position self in a face-down position for 4 to 5 days.
- C. Assume a side-lying position with the left side down for 3 days.
- D. Keep head upright and cushioned with pillows for 24 hours.
Correct Answer: B
Rationale: Following a vitrectomy, the patient must assume a face-down position or turn the face to the right side for 4 to 5 days.
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Which action is the first nursing intervention step for the immediate care of a patient with a penetrating wound of the eye?
- A. Assess eye, do not remove object.
- B. Cover both eyes with an eye shield or cup.
- C. Check for the irregularity of the pupil.
- D. Obtain medical attention immediately.
Correct Answer: C
Rationale: The patient should be placed on his back to prevent loss of the aqueous humor, assessment of the eye for the location of the object and whether the pupil is regular, cover the eye to prevent movement, and obtain medical attention immediately.
A patient who had an enucleation of the right eye has been admitted postoperatively to the nursing unit. Which aspect does the nurse expect to see in the plan of care?
- A. Turn, cough, and deep breathe every 3 hours.
- B. Apply a pressure dressing over the right eye socket.
- C. Document dressing Data Collection every 2 hours.
- D. Turn on the affected side.
Correct Answer: B
Rationale: A pressure dressing will be applied to the right eye socket and the dressing should be checked every hour for the first 24 hours.
The nurse clarifies that the difference between a photorefractive keratectomy (PRK) and a laser in-situ keratomileusis (LASIK) is that a LASIK is intended to improve vision in which way?
- A. reshapes the central cornea.
- B. makes partial-thickness radial incisions in the cornea.
- C. removes some internal layers of the cornea.
- D. implants intracorneal rings.
Correct Answer: C
Rationale: The LASIK procedure removes some of the internal layers of the cornea affecting the central zone of vision.
Which anatomical change is associated with diabetes retinopathy?
- A. Capillaries in retina hemorrhage
- B. Long-term overdosing of insulin
- C. Retinal detachment
- D. Aging
Correct Answer: A
Rationale: Retinopathy is caused when the capillaries in the retina have aneurysms or hemorrhage.
Which action should the nurse take when assisting a blind person to walk in an unfamiliar hospital environment?
- A. Discourage the use of the cane.
- B. Advise the patient to walk quickly.
- C. Describe the surroundings.
- D. Encourage the patient to ask for verbal cues.
- E. Place patient hand on nurse's shoulder or elbow.
Correct Answer: C,D,E
Rationale: The patient should be given verbal cues about the environment. Allow the patient to hold the nurse's shoulder or elbow while the nurse walks in front and encourage the use of a cane to let the patient 'examine' the boundaries and obstacles.