1.
Which of the following procedures or assessments must the nurse perform when preparing a client for eye surgery?
Correct Answer
C. Verifying the client has been NPO since midnight or at least 8 hours before surgery.
Explanation
The nurse must verify that the client has been NPO (nothing by mouth) since midnight or at least 8 hours before surgery. This is important to prevent aspiration and complications during anesthesia. Clipping the client's eyelashes is not necessary for eye surgery. Verifying if the affected eye has been patched 24 hours before surgery is not standard for all eye surgeries. Trimming facial hair is not required before eye surgery.
2.
Cataract surgery results in aphakia. Which of the following statements best describes this term?
Correct Answer
A. Absence of the crystalline lens
Explanation
Aphakia refers to the absence of the crystalline lens in the eye. During cataract surgery, the cloudy lens is removed and replaced with an artificial lens, resulting in aphakia. The crystalline lens is responsible for focusing light onto the retina, so its absence can cause a significant loss of visual acuity. Patients with aphakia often require corrective lenses, such as glasses or contact lenses, to improve their vision.
3.
When developing a teaching session on glaucoma for the community, which of the following statements would the nurse stress?
Correct Answer
D. Glaucoma can be painless, and vision may be lost before the person is aware of a problem.
Explanation
An important teaching point is "Glaucoma can be painless, and vision may be lost before the person is aware of a problem" because it highlights an important aspect of glaucoma. This statement emphasizes the need for regular eye exams and early detection of glaucoma, as it can progress silently without any symptoms until significant vision loss occurs. By educating the community about this, the nurse can raise awareness about the importance of regular eye screenings and prompt treatment to prevent irreversible vision loss.
4.
For a client having an episode of acute narrow-angle glaucoma. Which of the following medications does a nurse expect to give?
Correct Answer
A. Acetazolamide (Diamox)
Explanation
Acute narrow-angle glaucoma is a condition characterized by increased pressure in the eye due to blocked drainage channels. Acetazolamide (Diamox) is a medication commonly used to reduce intraocular pressure in glaucoma. It works by inhibiting the enzyme carbonic anhydrase, which reduces the production of aqueous humor in the eye. Atropine is not typically used for acute narrow-angle glaucoma, as it can worsen the condition by dilating the pupil and causing the iris to block the drainage angle. Furosemide (Lasix) is a diuretic that is not indicated for glaucoma. Urokinase is a thrombolytic agent used to dissolve blood clots and is not relevant to the treatment of glaucoma.
5.
Which of the following symptoms would occur in a client with a detached retina?
Correct Answer
A. Flashing lights and floaters
Explanation
A detached retina occurs when the retina, the thin layer of tissue at the back of the eye, becomes separated from its normal position. This can cause the patient to experience flashing lights and floaters. Flashing lights are caused by the retina being tugged or pulled, while floaters are small specks or clouds that appear in the field of vision. These symptoms are often described as seeing flashes of light or spots moving across the visual field. Homonymous hemianopia refers to a visual field defect where half of the vision is lost in both eyes, while loss of central vision refers to a decrease or complete loss of vision in the center of the visual field. Ptosis is a drooping of the upper eyelid and is not directly related to a detached retina.
6.
A male patient has just had a cataract operation without a lens implant. In discharge teaching. The nurse will instruct the client’s wife to:
Correct Answer
D. Allow him to walk upstairs only with assistance.
Explanation
After a cataract operation without a lens implant, the client may experience temporary vision impairment and difficulty navigating stairs. Allowing him to walk upstairs only with assistance ensures his safety and reduces the risk of falls or accidents. This instruction promotes a cautious approach to prevent any strain or injury to the client's eyes during the recovery period.
7.
The nurse is performing a voice test to assess hearing. Which of the following describes the accurate procedure for performing this test?
Correct Answer
B. Whisper a statement and ask the client to repeat it.
Explanation
The accurate procedure for performing a voice test to assess hearing is to whisper a statement and ask the client to repeat it. This allows the nurse to determine if the client can hear and understand the whispered statement clearly. Standing 4 feet away from the client is not necessary for this test, and whispering with the examiner's back facing the client or while the client blocks both ears would not provide an accurate assessment of hearing ability.
8.
During the early postoperative period. The client who had a cataract extraction complains of nausea and severe eye pain over the operative site. The initial nursing action is to:
Correct Answer
A. Call the pHysician
Explanation
The initial nursing action should be to Call the physician. Severe eye pain and nausea are not typical postoperative symptoms after a cataract extraction and could indicate complications such as increased intraocular pressure or infection. Therefore, it’s important to report these symptoms to the physician immediately for further evaluation. While administering medication may be part of the management plan, it should be done based on the physician’s guidance.
9.
The nurse is caring for a client that is hearing impaired. Which of the following approaches will facilitate communication?
Correct Answer
D. Speak in a normal tone
Explanation
When caring for a hearing impaired client, speaking in a normal tone is the most appropriate approach to facilitate communication. Speaking frequently or loudly may not necessarily improve understanding for the client, and speaking directly into the impaired ear may not be effective if the client has bilateral hearing loss. Speaking in a normal tone allows the client to lip-read and use any residual hearing they may have, making it easier for them to understand and engage in conversation.
10.
The nurse has conducted discharge teaching for a client who had a fenestration procedure for the treatment of otosclerosis. Which of the following, if stated by the client, would indicate that teaching was effective?
Correct Answer
C. “I will take stool softeners as prescribed by my doctor.”
Explanation
The correct answer is "I will take stool softeners as prescribed by my doctor." This statement indicates that the client understands the importance of taking stool softeners to prevent constipation, which is a common side effect of the procedure and the associated pain medication. It shows that the client is aware of the post-operative instructions and is willing to follow them, demonstrating effective teaching. The other options are unrelated to the procedure or do not reflect the necessary precautions and care needed after the surgery.