Saunders EYE
While at home, the nurse receives a telephone call from a neighbor who reports that while accidentally breaking a mirror, a piece of glass flew into her eye. Which is the appropriate initial nursing action after observing that the large glass shard is protruding from the neighbor's eye? 1.Secure a paper cup over the affected eye. 2.Flush the eye thoroughly with tap water. 3.Remove the piece of glass using tweezers. 4.Accompany the victim to the emergency department.
1
The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures should the nurse include in the plan? Select all that apply. 1.To avoid activities that require bending over 2.To contact the surgeon if eye scratchiness occurs 3.To take acetaminophen for minor eye discomfort 4.To place an eye shield on the surgical eye at bedtime 5.That episodes of sudden severe pain in the eye are expected 6.To contact the surgeon if a decrease in visual acuity occurs
1,3,4,6
The nurse is reinforcing discharge instructions to a client going home after same-day eye surgery. During the postoperative period, the nurse stresses that the client may safely perform which activity? 1.Watch television. 2.Read newspapers. 3.Bend below the waist. 4.Lift objects up to 20 pounds.
1
A client arrives in the emergency department with a chemical eye injury. The nurse immediately performs which action? 1.Performs visual acuity tests 2.Covers the eye with a pressure patch 3.Swabs the eye with an antibiotic ointment 4.Irrigates the eye with copious amounts of sterile normal saline
4
A client arrives in the emergency department with a foreign body in the eye. Which action should the nurse plan to perform first? 1.Apply an eye patch to both eyes. 2.Irrigate the eye with sterile saline. 3.Apply nonsteroidal anti-inflammatory ointment. 4.Assist the primary healthcare provider to check for corneal abrasions.
1
A client arrives at the emergency department following a blow to the eye from a softball. Which intervention should be implemented by the nurse initially? 1.Apply ice to the affected eye. 2.Perform a thorough eye examination. 3.Irrigate the eye with sterile, cool water. 4.Place the client in a supine position on a stretcher.
1
A client arrives in the emergency department following an eye injury from a chemical solution. Which is the initial nursing action? 1.Test the eye pH with litmus paper. 2.Obtain a medical history from the client. 3.Cover the eye with sterile saline solution, and contact the primary health care provider. 4.Place a pressure dressing on the eye until the client's primary health care provider arrives.
1
Which are age-related changes to the eyes? Select all that apply. 1.Presbyopia 2.Arcus senilis 3.Yellow-tinged sclera 4.Decreased astigmatism 5.Increased color discrimination 6.Decreased ability to see in dim light
1,2,3,6
A clinic nurse is reinforcing home care instructions to a client with a diagnosis of glaucoma. Which statement by the client indicates an understanding of the treatment plan for glaucoma? 1."I can use salt only for cooking." 2."I need to take my eye drops for the rest of my life." 3."I need to restrict my fluid intake to 4 glasses daily." 4."I need to limit my amount of reading to 2 hours a day.
2
A nursing student is caring for a client in the health care clinic who has been diagnosed with glaucoma. The client has a history of heart disease. The nursing instructor asks the student about group of medications used to treat glaucoma that would be contraindicated? 1.Sympathomimetic agents 2.Alpha2-adrenergic agonist 3.Cholinergic miotic agents 4.Carbonic anhydrase inhibitor agents
2
The nurse in a health care clinic is assisting in testing the client for accommodation. Arrange the actions and observations in the order that they should occur. All options must be used.
focus distant pupils dilate focus close pupils constrict document
A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel and a hyphema has been diagnosed. Which position should the nurse prepare to position the client? 1.Flat on bed rest 2.On bed rest in a semi-Fowler's position 3.In lateral position on the unaffected side 4.In the lateral position on the affected side
2
A client diagnosed with primary open-angle glaucoma has been prescribed pilocarpine ophthalmic drops. The nurse has given the client instructions on how to administer the eye drops. Which client statement indicates a need for further teaching? 1."I will pull down on the lower lid." 2."I will drop the eye drop in the middle of my eye." 3."I will sit and tilt my head slightly to the side I am giving the eye drops." 4."I will close my eyes gently and move my eyes side to side under the lids."
2
A client is brought to the ambulatory care department by the spouse 1 day following a cataract extraction procedure. A diagnosis of hyphema is made, which occurred as a result of the surgical procedure. The nurse reinforces instructions to the client and spouse regarding the treatment for the complication and makes which statement? 1."Ambulate as necessary." 2."Maintain bed rest and patching of both eyes." 3."Resume normal activities because the hyphema will resolve on its own." 4."Return to the outpatient department for removal of the intraocular lens implant."
2
A client reporting recent right eye discomfort is diagnosed with chalazion of the right eye. The nurse reinforces instructions to the client regarding care to the eye. Which statement by the client indicates an understanding of the measures? 1."I should apply cold packs to my eye." 2."I should apply warm packs to my eye." 3."I should irrigate my eye with cool water daily." 4."I should use separate washcloths and towels to prevent spreading the infection."
2
In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops. The nurse administers the eye drops knowing that which is the purpose of this medication? 1.To produce miosis of the operative eye 2.To dilate the pupil of the operative eye 3.To provide lubrication to the operative eye 4.To constrict the pupil of the operative eye
2
Pilocarpine hydrochloride is prescribed for the client with glaucoma. Which medication should the nurse plan to have available in the event of systemic toxicity? 1.Metipranolol 2.Atropine sulfate 3.Timolol maleate 4.Carteolol hydrochloride
2
The instructor is quizzing the student nurse concerning care of a visually impaired client. Which statement indicates a need for further teaching? 1."I will announce myself when I enter or leave the room." 2."I will take the client's arm to lead while we are walking." 3."I will keep all doors either fully open or completely closed." 4."I will speak in a normal tone of voice when explaining procedures."
2
A client arrives at the emergency department after experiencing a traumatic blow to the eye and a hyphema is diagnosed. In which position should the nurse place the client? 1.Prone 2.Supine 3.In semi-Fowler's position 4.In Trendelenburg's position
3
A client arrives at the emergency department following an eye injury in which an acid used to clean the brick on the fireplace splashed into the eye. Which question should the nurse ask initially? 1."What time did the injury occur?" 2."What type of acid caused the injury?" 3."Did you flush the eye following the injury?" 4."Did you bring the container of acid with you?"
3
The nurse in the recovery room area is preparing to care for a client following cataract extraction of the right eye. Which position does the nurse prepare to place the client? 1.Supine with head turned to affected side 2.Supine with head turned to unaffected side 3.On the left side with the head of the bed elevated 4.On the right side with the head of the bed elevated
3
The nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse should take which appropriate action? 1.Document the finding. 2.Continue to monitor vital signs. 3.Report the finding to the registered nurse (RN). 4.Mark the drainage on the dressing and monitor for any increase in bleeding.
3
The nurse is caring for a client following enucleation. On data collection, the nurse notes staining and bleeding on the dressing. The nurse should take which action? 1.Document the findings. 2.Reinforce the dressing. 3.Notify the registered nurse. 4.Mark the amount of staining with a black pen.
3
The nurse should check for vision loss in a client with which condition? 1.Urosepsis 2.Otitis media 3.Diabetes mellitus 4.Nephrotic syndrome
3
The nurse reinforces home care instructions to a client after cataract removal and placement of an intraocular implant in the right eye. Which statement by the client indicates a need for further teaching? 1."I need to avoid lying on my right side." 2."I need to wear the metal eye shield at night when I sleep." 3."I should take stool softeners to prevent becoming constipated." 4."I need to remove the eye dressing as soon as I get home and place a warm pack on my eye."
4
These are signs and symptoms of glaucoma. Which sign or symptom is found only in narrow-angle glaucoma? 1.Blurred or hazy vision 2.Colored rings around lights 3.Tonometry reading 30 mm Hg 4.Severe pain in and around eye
4
A client has been admitted to the telemetry unit with a diagnosis of bradycardia. The nurse is reviewing the client's prescriptions with the registered nurse. The client has a history of open-angle glaucoma. Which prescription should the nurse suggest should be questioned? 1.Atropine intravenously 2.Docusate sodium 100 mg po daily 3.Low sodium diet with limited caffeine 4.May take home pilocarpine eye drops
1
The nurse is inserting soft contact lenses into the eyes of a client. Which direction does the nurse tell the client to look? 1.Straight ahead 2.Upward and outward 3.Downward and inward 4.Downward and outward
1
Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse reviews the test and determines that the intraocular pressure is normal if which result is noted? 1.2 mm Hg 2.15 mm Hg 3.30 mm Hg 4.35 mm Hg
2
A client with glaucoma asks the nurse if complete vision will return. The nurse should make which response to the client? 1."Your vision will never return to normal." 2."Your vision will return as soon as the medication begins to work." 3."Your vision loss is temporary and will return in about 3 to 4 weeks." 4."Although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan."
4
The nurse is reviewing the results of an eye examination on a client. Which tests can detect glaucoma? Select all that apply. 1.Tonometry 2.Snellen chart 3.Visual field check 4.Electroretinography 5.Fluorescein angiography
1,3
Which diagnostic test would verify the diagnosis of macular degeneration? 1.Tonometer 2.Snellen chart 3.Amsler grid test 4.Ishihara chart book
3
A client arrives in the emergency department with an eye injury resulting from metal fragments that hit the eye while the client was drilling into metal. The nurse checks the eye and notes small pieces of metal floating on the eyeball. Which action should the nurse take first? 1.Apply an eye patch. 2.Irrigate the eye with sterile saline. 3.Perform complete visual acuity tests. 4.Remove the objects using a sterile eye clamp.
2
A client has been diagnosed with glaucoma. The nurse who is teaching the client principles of self-care should encourage the client to limit or refrain from which usual activity on a repeated basis? 1.Ironing 2.Peeling vegetables 3.Picking objects up off the floor 4.Folding clothes on a laundry table
3
A client is diagnosed with hyphema after experiencing a traumatic blow to the eye. The nurse explains to the client that which activity limitation needs to be implemented following this type of injury? 1.Bathroom privileges only 2.Ambulation within the room only 3.Bed rest with the head of the bed flat 4.Bed rest with the head in semi-Fowler's position
4
The nurse is attempting to inspect the lacrimal apparatus of a client's eye. Because of its anatomical location, the nurse should do which action? 1.Retract the upper eyelid and ask the client to look up. 2.Retract the lower eyelid and ask the client to look up. 3.Retract the lower eyelid and ask the client to look down. 4.Retract the upper eyelid and ask the client to look down.
4
The nurse is gathering data from a client with a history of untreated cataracts. The nurse asks the client about the presence of which sign of a cataract? 1.A blank spot in the field of vision 2.Pain in the eyes when in dim light 3.Either excessive itching or tearing of the eyes 4.Difficulty with driving at night and blurred vision
4
The nurse is reviewing the medical record of a client diagnosed with conjunctivitis. Which signs and symptoms should the nurse expect to be noted? Select all that apply. 1.Itching 2.Painless 3.Redness 4.Complaint of dry eyes 5.Sensation of foreign object
1,3,5
A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma? 1.Cardiovascular disease 2.A history of migraine headaches 3.Frequent urinary tract infections 4.Frequent upper respiratory infections
1
A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The nurse should take which immediate action? 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 is caring for a client following enucleation. Which postsurgical observation requires immediate attention by the nurse? 1.Bright red drainage on the dressing 2.A blood pressure of 122/84 mm Hg 3.Complaints of pain in the affected eye 4.A respiratory rate of 22 breaths per minute
1
The nurse collects data from a client with a diagnosis of macular degeneration of the eye. The nurse should expect the client to report which symptoms? Select all that apply. 1.Blurred central vision 2.Bending of straight lines 3.Loss of peripheral vision 4.Clear vision when reading 5.Inability to see color vividness
1,2,5
The nurse is reinforcing home care instructions to a client who has a hordeolum (sty) of the right eye. Which statement by the client indicates an understanding of the instructions? 1."I should apply antibiotic ointment as prescribed." 2."When the eyelid turns white, I should try to squeeze the sty." 3."I should press on the eye when I apply the warm compresses." 4."I need to apply cool compresses to the eye for 15 minutes 4 times daily."
1
The nurse has reinforced instructions to a client who is scheduled for a cataract extraction. Which statement by the client indicates a need for further teaching? 1."No eating or drinking for at least 18 hours before the surgery." 2."I will go home wearing a patch on my eye after the surgery." 3."A sedative will be prescribed to help me relax for the surgery." 4."I understand that I need to wash my face on the morning of surgery."
1
The nurse in the ambulatory care unit is caring for a client following cataract extraction. The client suddenly complains of nausea and severe eye pain in the surgical eye. The nurse should take which action? 1.Notify the registered nurse. 2.Apply ice to the operative eye. 3.Turn the client onto the operative side. 4.Administer the prescribed pain medication and antiemetic.
1
The nurse is reinforcing discharge instructions to a client following right eye corneal transplantation surgery. The nurse determines that the client understands the instructions if the client makes which statement? 1."I will lie on my back or left side." 2."I will wear my eye shield at all time." 3."I will remove my dressing and eye shield tonight." 4."I know to expect some inflammation near the graft edges."
1
The nurse is caring for a client with glaucoma. Which medication prescribed for the client should the nurse question? 1.Betaxolol 2.Pilocarpine 3.Atropine sulfate 4.Pilocarpine hydrochloride
3
A client has been newly diagnosed with glaucoma. As part of the discharge instructions, the nurse should plan to reinforce which information? 1.The need to decrease table salt in the diet 2.The need for lifelong medication therapy 3.The need to avoid straining or overworking the eyes 4.The need to restrict fluids in order to reduce intraocular pressure
2
A client who has undergone cataract removal without an intraocular lens implant is visibly upset because his vision is still blurry. Which action should the nurse perform to provide realistic reassurance to this client? 1.Explain that vision will improve with adjustment to aphakic lenses. 2.Reassure the client that bright color contrasts in the environment will help. 3.Tell the client that there are many resources available for those with impaired vision. 4.Determine whether the client knows any other people who have experienced blindness.
1
Immediately following cataract repair, the client's affected conjunctiva and eyelids are edematous. Which statement by the nurse accurately characterizes these findings for the client? 1."The edema is normal and should subside within 3 days." 2."The edema is abnormal because only the conjunctiva should be affected." 3."The edema is abnormal and should be reported if the swelling increases." 4."The edema is not unusual but should be reported if not improved within 24 hours."
1
The nurse is providing discharge instructions to a client who is postoperative cataract surgery on the left eye. Which statement indicates a need for further teaching? 1."I can't pick up my 10-pound dog for a while." 2."I got slip-on shoes since I can't bend over to tie my shoelaces." 3."I need to wear glasses during the day and sunglasses if I go outside." 4."If I have severe eye pain, I will take the narcotic pain pill that my doctor will prescribe for me."
4
The nurse is collecting data from a client who has a history of untreated cataracts. The nurse checks the client for which associated manifestation? 1.A blank spot in the field of vision 2.Difficulty with driving a car at night 3.Pain in the eyes when in dim light 4.Either excessive itching or tearing of the eyes
2
After an eye examination, a client has been diagnosed with acute angle-closure glaucoma. The nurse collecting data from the client asks the client about an accompanying history of which sign/symptom? 1.Eye pain 2.Color blindness 3.Yellow-green vision 4.Difficulty seeing at night
1
Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply. 1.Monitor for hemorrhage. 2.Administer eye medications. 3.Maintain the eye patch or shield. 4.Assist with activities of daily living. 5.Encourage coughing and deep breathing. 6.Educate regarding symptoms of retinal detachment.
1,2,34,6
A client with glaucoma and an acute exacerbation of chronic obstructive pulmonary disease (COPD) has a new prescription to receive carteolol HCl eye drops. Which action by the nurse is most appropriate? 1.Administer the medication as prescribed. 2.Withhold the dose and notify the registered nurse. 3.Vigorously shake the medication bottle to distribute the medication evenly. 4.Obtain a sample of eye drainage for culture before administering the medication.
2
Betaxolol hydrochloride eye drops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side/adverse effects of this medication? 1.Monitoring temperature 2.Monitoring blood pressure 3.Checking peripheral pulses 4.Checking the blood glucose level
2
The nurse is giving the client discharge instructions concerning glaucoma. Which client statement indicates a need for further teaching? 1."I will decrease night driving if possible." 2."I will only take the eye drops until my vision improves." 3."I will eat a low-sodium diet and decrease my caffeine intake." 4."I will take stress management classes to help decrease my stress."
2
The nurse is providing discharge instructions to a client following a keratoplasty. Which statement by the client indicates the need for further teaching? 1."I need to avoid bending over." 2."Sutures are removed in 2 weeks." 3."I need to avoid lifting heavy objects." 4."I need to avoid crowded environments and smoke-filled areas."
2
The nurse is reviewing the plan of care developed by a nursing student for a client scheduled for keratoplasty. The nurse discusses the plan with the student if which incorrect intervention is listed in the plan? 1.Cutting the client's eyelashes 2.Administering medications that will dilate the pupil 3.Instilling antibiotic ophthalmic medication as prescribed 4.Obtaining a culture and sensitivity with conjunctival swabs
2
A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse should tell the client which purpose? 1."The medication will help dilate the eye to prevent an increase in eye pressure." 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
The nurse has reinforced instructions to a client following a right keratoplasty. Which statement by the client indicates a need for further teaching? 1."I need to wear an eye shield at bedtime." 2."I will faithfully apply antibiotic medication." 3."In 1 week, I'll return to have the sutures removed." 4."It will be unusual to sleep on my left side, but I'll cope."
3
A client with retinal detachment is admitted to the outpatient nursing unit in preparation for a scleral buckling procedure. Which prescription should the nurse anticipate? 1.Bathroom privileges only 2.Elevating the head of the bed to 45 degrees 3.Wearing dark glasses to read or watch television 4.Placing an eye patch over the client's affected eye
4
After a routine eye examination, a client has been told there are refractive errors in both eyes. The nurse explains to the client that this problem is primarily treated with which intervention? 1.Eye drops 2.Keratoplasty 3.Rigid contact lenses 4.Prescription of corrective lenses
4
The nurse interprets that a client diagnosed with glaucoma needs additional information about the expected effects of this condition when the client makes which statement? 1."I have placed nightlights in my hallway at home." 2."I understand how important it is to have periodic eye examinations." 3."My family has begun driving me when I go shopping and running errands." 4."Taking my daily walk right around dusk each evening has proven to be so enjoyable."
4
The nurse is assigned to administer the prescribed eye drops for a client preparing for cataract surgery. Which type of eye drops should the nurse expect to be prescribed? 1.A miotic agent 2.A thiazide diuretic 3.An osmotic diuretic 4.A mydriatic medication
4
The nurse is reinforcing preoperative instructions to a client scheduled for cataract surgery and prepares a written list of instructions for the client. Which statement by the client indicates a need for further teaching? 1."My eyelashes may be cut before surgery." 2."Eye medications will be placed in my eye before the surgery." 3."I can drink any liquids that I want to on the morning of the surgery." 4."Medication may be given to me on the day of surgery to produce relaxation."
3
During the early postoperative stage, the client who had a cataract extraction complains of nausea and severe eye pain over the operative site. Which action should the nurse implement? 1.Report the client's complaints. 2.Reassure the client that this is normal. 3.Turn the client on his or her operative side. 4.Administer the prescribed pain medication and antiemetic.
1
The client is receiving an eye drop and an eye ointment to the right eye. Which action should the nurse take? 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 10 minutes, and administer the eye ointment. 4.Administer the eye ointment, wait 10 minutes, and administer the eye drop.
1
The nurse reinforces instructions to a client with glaucoma regarding measures that will prevent an increase in intraocular pressure in the eyes. Which statement by the client indicates a need for further teaching? 1."I can tie my shoelaces by bending over slowly." 2."I need to consume a diet high in fiber and bulk." 3."I need to maintain an intake of 6 to 8 glasses of water a day." 4."I can move objects weighing 20 pounds or more by pushing the object on the floor using the feet."
1
A client sustains a chemical eye injury from a splash of battery acid. The nurse should prepare the client for which immediate measure? 1.Checking visual acuity 2.Covering the eye with a pressure patch 3.Swabbing the eye with antibiotic ointment 4.Irrigating the eye with sterile normal saline
4
client who was hit in the eye with a baseball bat sustains a contusion of the eyeball. The emergency department nurse implements which immediate action? 1.Applies ice to the affected eye 2.Applies a warm saline compress 3.Irrigates the eye with cool water 4.Places an eye patch on the affected eye
1
A client who sustained an eye injury arrives at the emergency department. Which is the initial nursing action? 1.Instill an antibiotic solution. 2.Place an ice pack on the eye. 3.Flush the eye with sterile saline solution. 4.Obtain a history regarding the cause of the injury.
4
A client is being discharged from the ambulatory care unit following cataract removal, and the nurse provides instructions regarding home care. Which statement by the client indicates an understanding of the instructions? 1."I will take aspirin if I have any discomfort." 2."I will sleep on the side that I was operated on." 3."I will not lift anything if it weighs more than 10 pounds." 4."I will wear my eye shield at night and my glasses during the day."
4
The nurse is preparing to administer eye drops. Which interventions should the nurse take to administer the drops? Select all that apply. 1.Wash hands. 2.Put on gloves. 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
A client has bilateral aphakia. When reinforcing teaching instructions regarding the prescribed eyeglasses, the nurse determines the need for further teaching when the client makes which statement? 1."My peripheral vision will not be distorted." 2."I can expect my central vision to be corrected." 3."It may still be difficult for me to judge distances." 4."These glasses take the place of an intraocular lens insertion."
1
A client is being discharged from the ambulatory care unit following cataract removal. Which instruction from the discharge teaching plan should the nurse reinforce? 1.Take acetaminophen if any discomfort occurs. 2.Sleep on the side that was operated on to promote drainage. 3.Avoid wearing glasses for 48 hours postsurgery to rest ocular muscles. 4.Do not lift anything that weighs more than 10 pounds to minimize intraocular pressure.
1
A client with glaucoma has suffered significant eye damage before diagnosis and now has impaired vision. The nurse determines that the client needs further assistance in adapting to this situation if the client makes which statement? 1."There is no difficulty driving at dusk." 2."It is important to have periodic eye examinations." 3."Nightlights have been placed in the hallways for night use." 4."My family will drive me when eye examinations are needed
1
The nurse is preparing a plan of care for a client being admitted to the hospital with a diagnosis of retinal detachment. Which measure should the nurse include in the plan of care? 1.Restrict visitors. 2.Maintain high-Fowler's position. 3.Place an eye patch over the affected eye. 4.Permit getting out of bed to ambulate with assistance.
3
The nurse caring for a client in the postoperative period following an enucleation notes bloody staining on the surgical eye dressing. Which is the appropriate nursing action? 1.Contact the registered nurse. 2.Document the finding including color of the stain. 3.Without disturbing the original dressing, reinforce it. 4.Mark the stain site, and continue to monitor for further bleeding.
1
A client reports to the health care clinic for an eye examination, and a diagnosis of primary open-angle glaucoma is suspected. Which question will elicit information regarding the signs/symptoms associated with this disorder? 1."Do bright lights cause glare?" 2."Is your central vision blurred?" 3."Do you have any pain in your eyes?" 4."Have you had difficulty with peripheral vision?"
4
A client arrives at the emergency department for treatment of an injury to the eye after being hit by a baseball bat. On data collection, the nurse notes that the eye is bleeding. Which nursing action is appropriate? 1.Irrigate the eye. 2.Apply pressure to the eye. 3.Cover the eye with cold, sterile saline gauze. 4.Send the client to x-ray for a complete skull series.
3
The nurse is reinforcing discharge teaching to a client following right eye cataract surgery. The nurse determines that the client needs further teaching about ways to avoid strain on the operative eye when the client makes which statements? Select all that apply. 1."I cannot rub my eye." 2."I can lie on my right side." 3."I should take a stool softener." 4."I can't lift more than 5 pounds." 5."I will wear my eye shield only during the daytime."
2,5
The nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which should the nurse include in the preparations? Select all that apply. 1.Use a dry table that is below waist level. 2.Open the distal flap of a sterile package first. 3.Prepare the sterile field just before the planned procedure. 4.Don clean gloves before touching items on the sterile field. 5.Place the sterile field 1 foot behind the working area and out of view of the client. 6.Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field.
2,3,4,5
The nurse is reviewing the health record of a client diagnosed with a cataract. Which are signs and symptoms of cataract formation? Select all that apply. 1.Constant eye pain 2.Floaters in visual field 3.Difficulty in night vision 4.Increasing farsightedness 5.Decreased color perception
2,3,5
The nurse is assigned to care for a client with a diagnosis of detached retina. Which findings would indicate that bleeding has occurred as a result of retinal detachment? Select all that apply. 1.Total loss of vision 2.Vision may be cloudy 3.A reddened conjunctiva 4.A sudden sharp pain in the eye 5.Complaints of a burst of black spots or floaters 6.Vision is clear straight ahead but not to the right
2,5
A client has been diagnosed with cataracts. Which signs and symptoms should the nurse expect to note? Select all that apply. 1.Pain 2.Photophobia 3.Blurred vision 4.Decreased color perception 5.Progressive loss of peripheral vision 6.Flashes of colored light accompanied by showers of floaters
2,3,4
A client is brought to the emergency department by the ambulance team after collapse at home. Cardiopulmonary resuscitation is attempted but is unsuccessful. The wife of the client tells the nurse that the client is an organ donor and that their eyes are to be donated. Which action should the nurse take next? 1.Place dry, sterile dressings over the eyes of the deceased. 2.Call the National Donor Association to confirm that the client is a donor. 3.Close the eyes, elevate the head of the bed, and place a small ice pack on the eyes. 4.Ask the wife to obtain the legal documents regarding organ donation from the lawyer.
3
A client who had previously undergone cataract surgery tells the nurse that she has begun seeing flashing lights and floaters in the eye. Based on the client's history, the nurse interprets that the client is at risk for which? 1.Glaucoma 2.Papilledema 3.Detached retina 4.Recurrent cataract
3
Prescriptive glasses are prescribed for a client with bilateral aphakia, and the nurse reinforces instructions to the client regarding the use of the glasses. Which statement by the client indicates the need for further teaching? 1."Objects that I look at may be distorted." 2."It may be difficult to judge distances when I drive a car." 3."The prescriptive glasses will correct my visual field of sight." 4."The prescriptive glasses will magnify my central vision by 30%."
3
The nurse in the outpatient unit is preparing a client who is scheduled for a laser trabeculoplasty for the treatment of primary open-angle glaucoma. Which instructions should the nurse reinforce to the client? 1."The procedure takes about 2 hours." 2."Your vision loss will be restored following the procedure." 3."You may return to work 1 or 2 days following the procedure." 4."Activities can be resumed immediately following the procedure."
3
The nurse is giving home care instructions to a client with conjunctivitis. Which client statement indicates a need for further teaching? 1."I will use my own washcloth and not share it." 2."I will use the antibiotic eye drops as instructed." 3."I will use a sterile gauze to rub any matter from my eyes." 4."I will use warm or cool compresses, whichever feels better."
3
The nurse is reinforcing instructions to a client with a diagnosis of hordeolum regarding the treatment plan. Which instruction should the nurse include in the teaching plan for the client? 1.Avoid the use of antibiotic ointment. 2.Apply a cool compress to the eye twice daily. 3.Apply a warm compress for 15 minutes 4 times daily. 4.Press on the hordeolum after the warm compress to induce rupture.
3
The nurse is reviewing the preoperative prescriptions of a client scheduled for a keratoplasty. Which prescriptions noted in the client's chart should the nurse question? 1.Cut the client's eyelashes. 2.Obtain a culture and sensitivity of the conjunctiva. 3.Administer medication to dilate the affected pupil. 4.Administer prescribed antibiotic eye medication.
3
A clinic nurse is reviewing the record of a client recently diagnosed with a cataract. Which clinical manifestations associated with this disorder should the nurse expect to be documented in the client's record? Select all that apply. 1.Colored rings around lights 2.Increased color perception 3.Increasing nearsightedness 4.Need for more light when reading 5.Painless progressive loss of vision
3,4,5
The nurse is assigned to care for a client following a cataract extraction. The nurse plans to place the client in which position? 1.Prone 2.Supine 3.On the operative side 4.On the nonoperative side
4
The nurse is assigned to care for a client with a detached retina. Which finding should the nurse expect to be documented in the client's record? 1.Blurred vision 2.Pain in the effected eye 3.A yellow discoloration of the sclera 4.A sense of a curtain falling across the field of vision
4
The nurse is assisting in performing a confrontation test on a client seen in the clinic. The nurse understands that this test is performed to determine what? 1.The ratio of visual acuity 2.The intraocular pressure 3.If the lines become distorted or blurred 4.The ability to demonstrate effective peripheral vision
4
The nurse is assisting with developing a teaching plan for the client with glaucoma. Which instruction should the nurse suggest to include in the plan of care? 1.Decrease the amount of salt in the diet. 2.Decrease fluid intake to control the intraocular pressure. 3.Avoid reading the newspaper and watching television. 4.Eye medications may need to be administered for the rest of your life.
4
The nurse is providing instructions to a client who will be self-administering eye drops. To minimize the systemic effects that eye drops can produce, the client is instructed to perform 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 over the inner canthus for 30 to 60 seconds after instilling the drops.
4
The nurse is reinforcing discharge instructions to a client who has had ocular surgery of the left eye. Which statement by the client indicates a need for further teaching? 1."I need to wear an eye shield at night." 2."I need to wear sunglasses during the day." 3."I need to sleep on the back or the right side." 4."I need to call the doctor if I develop any fever."
4
The nurse is reinforcing instructions to a client regarding the use of ice packs to treat an eye injury. The nurse instructs the client to do which action? 1.Place the ice pack directly on the eye. 2.Avoid the use of commercially prepared ice bags. 3.Keep the ice pack on the eye continuously for 24 hours. 4.Wrap a plastic bag filled with ice with a pillowcase and place it on the eye.
4
A client has been diagnosed with open-angle glaucoma. Which signs and symptoms are found in open-angle glaucoma? Select all that apply. 1.Blurred or hazy vision 2.Colored rings around lights 3.Tonometry reading 30 mm Hg 4.Severe pain in or around the eye 5.Widening of vision at the sides of one or both eyes
1,2,3
The nurse is providing client and family instructions for a client who has been recently diagnosed with glaucoma. Which statement indicates that the client's family member needs further teaching regarding the eye drop application of pilocarpine hydrochloride? Select all that apply. 1."I should apply the eye drops directly over my family member's pupil." 2."I will apply the eye drops into a sac made by pulling down on his lower eyelid." 3."I have to contact the prescriber if my family member develops a small pupil." 4."I should count the drops as I'm applying them to ensure the accurate number is given." 5."I need to wipe off the tip of the eye drop bottle with a tissue between administrations."
1,3,5
The nurse is providing client teaching regarding glaucoma. Which instructions are important to include in the teaching plan? Select all that apply. 1.Follow a low-sodium, minimal-caffeine diet with plenty of fiber. 2.Expect your pupil to be dilated following administration of eye drops. 3.Place your eye drops directly over your pupil to ensure best absorption. 4.Be sure to report halos of light or increased eye pain to your primary health care provider. 5.You will be able to discontinue use of your eye drops when your vision improves.
1,4
A client has been diagnosed with macular degeneration. The nurse should expect to expect which signs and symptoms noted with macular degeneration? Select all that apply. 1.Blurred vision 2.Increasing nearsightedness 3.Increasing complaints about glare 4.Inability to see the vividness of colors 5.Objects that appear to be the wrong size
1,4,5
The nurse notes that the client's physical examination record states the client's eyes moved normally through the six cardinal fields of gaze. The nurse makes which interpretation? 1.The client has normal central vision. 2.The client has normal corneal reflexes. 3.The client has normal peripheral vision. 4.The client has normal ocular movements.
4
