Exam 3 - eye/ear/pain/surgery

A client is prescribed an eye drop and an eye ointment for the right eye. How would the nurse best administer the medications? 1. Administer the eye drop first, followed by the eye ointment. 2. Administer the eye ointment first, followed by the eye drop. 3. Administer the eye drop, wait 20 minutes, and administer the eye ointment. 4. Administer the eye ointment, wait 20 minutes, and administer the eye drop.

1

A client was working in the garden when insecticide accidentally sprayed into the right eye. The client calls the emergency department, frantic and screaming for help. The nurse would instruct the client to take which immediate action? 1. Irrigate the eyes with water. 2. Come to the emergency department. 3. Call the primary health care provider (PHCP). 4. Irrigate the eyes with diluted hydrogen peroxide.

1

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result would be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? 1. Hemoglobin, 8.0 g/dL (80 mmol/L) 2. Sodium, 145 mEq/L (145 mmol/L) 3. Serum creatinine, 0.8 mg/dL (70.6 mcmol/L) 4. Platelets, 210,000 cells/mm3 (210 × 109/L)

1

During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What would be the initial nursing action? 1. Call the surgeon. 2. Reassure the client that this is normal. 3. Turn the client onto their operative side. 4. Administer the prescribed pain medication and antiemetic.

1

The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention would be initiated immediately? 1. Apply ice to the affected eye. 2. Irrigate the eye with cool water. 3. Notify the primary health care provider (PHCP). 4. Accompany the client to the emergency department.

1

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? 1. Urinary output of 20 mL/hr 2. Temperature of 37.6° C (99.6° F) 3. Blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical dressing

1

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? 1. Increasing restlessness 2. A pulse of 86 beats per minute 3. Blood pressure of 110/70 mm Hg 4. Hypoactive bowel sounds in all four quadrants

1

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test? 1. The right eye is tested, followed by the left eye, and then both eyes are tested. 2. Both eyes are assessed together, followed by an assessment of the right eye and then the left eye. 3. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the largest line on the chart. 4. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the line that can be read 200 feet (60 meters) away by an individual with unimpaired vision.

1

The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse needs to call the surgeon to clarify that which medication would be given to the client and not withheld? 1. Prednisone 2. Ferrous sulfate 3. Cyclobenzaprine 4. Conjugated estrogen

1

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? 1. "Use of an incentive spirometer will help prevent pneumonia." 2. "Close monitoring of your oxygen saturation will detect hypoxemia." 3. "Administration of intravenous fluids will prevent or treat fluid imbalance." 4. "Early ambulation and administration of blood thinners will prevent pulmonary embolism."

1

The nurse prepares a client for ear irrigation as prescribed by the primary health care provider. Which action would the nurse take when performing the procedure? 1. Warm the irrigating solution to 98.6° F (37.0° C). 2. Position the client with the affected side up following the irrigation. 3. Direct a slow, steady stream of irrigation solution toward the eardrum. 4. Assist the client to turn their head so that the ear to be irrigated is facing upward.

1

The nurse receives a telephone call from the postanesthesia care unit, stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? 1. Assess the patency of the airway. 2. Check tubes or drains for patency. 3. Check the dressing to assess for bleeding. 4. Assess the vital signs to compare with preoperative measurements.

1

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions would the nurse take? Select all that apply. 1.Contact the surgeon. 2.Instruct the client to remain quiet. 3.Prepare the client for wound closure. 4.Document the findings and actions taken. 5.Place a sterile saline dressing and ice packs over the wound. 6.Place the client in a supine position without a pillow under the head.

1,2,3,4

The nurse is preparing to administer eye drops to a client being prepared for cataract surgery. Which actions would the nurse take to administer the drops? Select all that apply. 1. Wash hands. 2. Put gloves on. 3. Place the drop in the conjunctival sac. 4. Pull the lower lid down against the cheekbone. 5. Instruct the client to squeeze the eyes shut after instilling the eye drop. 6. Instruct the client to tilt the head forward, open the eyes, and look down

1,2,3,4

The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures would the nurse include in the plan? Select all that apply. 1. Avoid activities that require bending over. 2. Contact the surgeon if eye scratchiness occurs. 3. Take acetaminophen for minor eye discomfort. 4. Expect episodes of sudden severe pain in the eye. 5. Place an eye shield on the surgical eye at bedtime. 6. Contact the surgeon if a decrease in visual acuity occurs.

1,3,5,6

A client arrives in the emergency department following an automobile crash. The client's forehead hit the steering wheel, and a hyphema is diagnosed. The nurse would place the client in which position? 1. Flat in bed 2. A semi-Fowler's position 3. Lateral on the affected side 4. Lateral on the unaffected side

2

A client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action? 1. Apply an eye patch. 2. Perform visual acuity tests. 3. Irrigate the eye with sterile saline. 4. Remove the piece of wood using a sterile eye clamp.

2

A client is diagnosed with a problem involving the inner ear. Which is the most common client complaint associated with a problem involving this part of the ear? 1. Pruritus 2. Tinnitus 3. Hearing loss 4. Burning in the ear

2

A client with Ménière's disease is experiencing severe vertigo. Which instruction would the nurse give to the client to assist in controlling the vertigo? 1. Increase sodium in the diet. 2. Avoid sudden head movements. 3. Lie still and watch the television. 4. Increase fluid intake to 3000 mL a day.

2

A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action would the nurse implement based on this finding? 1. Provide the client with materials on legal blindness. 2. Instruct the client that glasses may be needed when driving. 3. Inform the client of where to purchase a white cane with a red tip. 4. Inform the client that it is best to sit near the back of the room when attending lectures.

2

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. Hard reddened skin 2. Serous drainage 3. Purulent drainage 4. Warm, tender skin

2

Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What would be the nurse's initial action? 1. Apply normal saline drops. 2. Note the time of day the test was done. 3. Contact the primary health care provider (PHCP). 4. Instruct the client to sleep with the head of the bed flat.

2

A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some noisy sounds in my ears, especially when I am alone." Which medication would the nurse identify as the cause of the client's complaint? 1. Doxycycline 2. Atropine sulfate 3. Acetylsalicylic acid 4. Diltiazem hydrochloride

3

A miotic medication has been prescribed for the client with glaucoma, and the client asks the nurse about the purpose of the medication. Which response would the nurse provide to the client? 1. "The medication will help dilate the eye to prevent pressure from occurring." 2. "The medication will relax the muscles of the eyes and prevent blurred vision." 3. "The medication causes the pupil to constrict and will lower the pressure in the eye." 4. "The medication will help block the responses that are sent to the muscles in the eye."

3

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. "If it's any help, everyone is nervous before surgery." 2. "I will be happy to explain the entire surgical procedure to you." 3. "Can you share with me what you've been told about your surgery?" 4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

3

Betaxolol hydrochloride eye drops have been prescribed for a client with glaucoma. Which nursing action is most appropriate related to monitoring for side and adverse effects of this medication? 1. Assessing for edema 2. Monitoring temperature 3. Monitoring blood pressure 4. Assessing blood glucose level

3

In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops at 0900 for surgery that is scheduled for 0915. What initial action would the nurse take in relation to the characteristics of the medication action? 1. Provide lubrication to the operative eye prior to giving the eye drops. 2. Call the surgeon, as this medication will further constrict the operative pupil. 3. Consult the surgeon, as there is not sufficient time for the dilative effects to occur. 4. Give the medication as prescribed; the surgeon needs optimal constriction of the pupil.

3

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement? 1. "Aspirin can cause bleeding after surgery." 2. "Aspirin can cause my ability to clot blood to be abnormal." 3. "I need to continue to take the aspirin until the day of surgery." 4. "I need to check with my doctor about the need to stop the aspirin before the scheduled surgery."

3

The nurse is caring for a client following enucleation to treat an ocular tumor and notes the presence of bright red drainage on the dressing. Which action would the nurse take at this time? 1. Document the finding. 2. Continue to monitor the drainage. 3. Notify the primary health care provider (PHCP). 4. Mark the drainage on the dressing and monitor for any increase in bleeding.

3

The nurse is caring for a hearing-impaired client. Which approach will facilitate communication? 1. Speak loudly. 2. Speak frequently. 3. Speak at a normal volume. 4. Speak directly into the impaired ear.

3

The nurse is creating a plan of care for a client scheduled for surgery. The nurse would include which activity in the nursing care plan for the client on the day of surgery? 1. Avoid oral hygiene and rinsing with mouthwash. 2. Verify that the client has not eaten for the last 24 hours. 3. Have the client void immediately before going into surgery. 4. Report immediately any slight increase in blood pressure or pulse.

3

The nurse is developing a teaching plan for a client with glaucoma. Which instruction would the nurse include in the plan of care? 1. Avoid overuse of the eyes. 2. Decrease the amount of salt in the diet. 3. Eye medications will need to be administered for life. 4. Decrease fluid intake to control the intraocular pressure.

3

The nurse notes that the primary health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action would the nurse take? 1. Speak loudly but mumble or slur the words. 2. Speak loudly and clearly while facing the client. 3. Speak at normal tone and pitch, slowly and clearly. 4. Speak loudly and directly into the client's affected ear.

3

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse would take which most appropriate action in the care of this client? 1. Obtain a court order for the surgery. 2. Have the charge nurse sign the informed consent immediately. 3. Send the client to surgery without the consent form being signed. 4. Obtain a telephone consent from a family member, following agency policy.

4

The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery? 1. Cranial nerve I, olfactory 2. Cranial nerve IV, trochlear 3. Cranial nerve III, oculomotor 4. Cranial nerve VII, facial nerve

4

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse needs to include which piece of information in discussions with the client? 1. Inhale as rapidly as possible. 2. Keep a loose seal between the lips and the mouthpiece. 3. After maximum inspiration, hold the breath for 15 seconds and exhale. 4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

4

The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye problem? 1. Total loss of vision 2. Pain in the affected eye 3. A yellow discoloration of the sclera 4. A sense of a curtain falling across the field of vision

4

The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation would the nurse expect to note in the early stages of cataract formation? 1. Diplopia 2. Eye pain 3. Floating spots 4. Blurred vision

4

The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding would the nurse expect to observe? 1. A pink-colored tympanic membrane 2. A pearly colored tympanic membrane 3. A transparent and clear tympanic membrane 4. A red, dull, thick, and immobile tympanic membrane

4

The nurse is providing instructions to a client who will be self-administering eye drops. To minimize systemic absorption of the eye drops, the nurse would instruct the client to take which action? 1. Eat before instilling the drops. 2. Swallow several times after instilling the drops. 3. Blink vigorously to encourage tearing after instilling the drops. 4. Occlude the nasolacrimal duct with a finger after instilling the drops.

4

Which medication, if prescribed for the client with glaucoma, would the nurse question? 1. Betaxolol 2. Pilocarpine 3. Erythromycin 4. Atropine sulfate

4

1. A client taking newly prescribed gabapentin for persistent neuropathic pain reports dizziness. What is the best nursing response? A. "This is a common side effect of gabapentin and will decrease with use." B. "Stop taking the medication and contact the health care provider." C. "The dizziness is caused by the neuropathic pain, not the medication." D. "The dizziness is likely from another medication, not the gabapentin."

A

Which communication method is appropriate when the nurse is interacting with a client who is deaf? A. Use pictures and writing B. Speak with enunciated words C. Ask client to read the nurse's lips D. Dialogue with the client's caregivers

A

Which symptom will the nurse teach the client who just had surgery to correct a retinal detachment to immediately report to the eye care provider? Select all that apply. A. Pain in the affected eye B. Pus in the affected eye C. Decreased visual acuity D. Temperature of 99.0°F E. Pupil that constricts in response to light

A,b,c

A client who was bitten by a spider develops cellulitis of the left lower arm. What assessment findings will the nurse expect when caring for this client? Select all that apply. A. Fever B. Pain C. Redness around the spider bite D. Warmth in the affected arm E. Swelling of the affected arm

A,b,c,d,e

When teaching a community group of older adults, what information will the nurse include regarding normal hearing changes associated with aging? Select all that apply. A. Hair in the ear thins and falls out B. Hearing acuity changes in all older adults C. Cerumen dries and becomes impacted more easily D. The ability to hear low-frequency pitches diminishes first E. Sounds such as f, s, sh, and pa may be more difficult to discern

A,c

The nurse is completing a preoperative physical assessment for a client who will have surgery this afternoon. Which assessment finding will the nurse report to the operative team? Select all that apply. A. Left arm prosthesis B. Skin turgor <3 seconds C. Blood pressure 160/100 mm Hg D. Presence of chest rigidity E. Has been NPO since midnight F. Expressed concern about surgery payment

A,c,d

Which assessment data do the nurse anticipate when a client presents to the emergency department reporting the sensation of a foreign body in the eye? Select all that apply. A. Pain B. Fever C. Tearing D. Photophobia E. Blurred vision

A,c,d,e

A client has been receiving the same dose of an intravenous opioid for 2 days to manage postsurgical pain. The client reports that the drug is no longer controlling the pain. What does the nurse suspect? A. There is likely a history of addiction. B. Tolerance to the opioid is developing. C. Physical dependence is developing. D. The client is opioid naïve.

B

A client is diagnosed with C. difficile infection. What nursing action is the priority for the client? A. Provide meticulous skin care. B. Place the client on Contact Precautions. C. Give the client an antipyretic medication. D. Encourage the client to drink extra fluids.

B

The nurse is caring for a postoperative patient who has asked for pain medicine an hour before it is due. What is the priority nursing response? A. "You cannot have more pain medicine until an hour from now." B. "Can you describe the pain you are having, and rate it on a 1-to-10 scale?" C. "I can help you begin a pain diary so we can see trends when your pain worsens." D. "Let's try some relaxation exercises to help address the discomfort you are feeling."

B

What teaching will the nurse provide to a client who has just been fitted for new hearing aids? A. Turn off the hearing aid when not using it. B. Immerse the ear mold in alcohol to fully clean it. C. Store the hearing aid in a warm, humid bathroom when not in use. D. Avoid using hair spray, makeup, and personal care products around the device.

D