A client is 1-day post-operative from cataract surgery.
Which of the following comments made by the client should the nurse report to the client's healthcare provider?
My eye is starting to really hurt me. I can't stand it.
I am making sure I don't bend at the waist.
I am avoiding scratching my eyes.
I am only wearing my eye patch at night.
The Correct Answer is A
Choice A rationale
Severe pain following cataract extraction is an abnormal finding that typically indicates a significant complication such as secondary glaucoma or ocular hemorrhage. Postoperative discomfort is expected to be mild, often described as a scratchy or itchy sensation. Intense pain suggests a rapid rise in intraocular pressure, which is a medical emergency. Normal intraocular pressure ranges from 10 to 21 mmHg. Reporting this immediately allows for rapid intervention to prevent permanent vision loss.
Choice B rationale
Bending at the waist is a physical action that significantly increases intraocular pressure by shifting fluid dynamics and increasing venous congestion in the head. Patients are instructed to avoid this movement to protect the surgical site and the newly implanted lens. Since the client is correctly following postoperative instructions to prevent pressure spikes, this comment is appropriate and does not require a report to the provider. It shows the client understands the safety precautions necessary for healing.
Choice C rationale
Scratching or rubbing the eye after surgery introduces a high risk of mechanical trauma to the incision site and potentially introduces pathogenic bacteria, leading to endophthalmitis. The eye is vulnerable during the initial healing phase of one to two days. By consciously avoiding this behavior, the client is minimizing the risk of infection and wound dehiscence. This statement reflects good adherence to the care plan and does not indicate a postoperative complication requiring medical notification.
Choice D rationale
Eye patches or shields are commonly prescribed for use during sleep to prevent accidental rubbing or pressure on the eye while the patient is unconscious. During the day, the patient may not need the patch if they are wearing glasses for protection. Since the client is using the patch as directed during the most vulnerable time of rest, this behavior is standard and expected. It does not signify a clinical problem that the healthcare provider needs to address.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
Step 1 is 320 mg ÷ 160 mg × 5 mL.
Step 2 is 2 × 5 mL.
Step 3 is 10.0 mL. The final calculated answer is 10 mL.
Correct Answer is C
Explanation
Choice A rationale
Vision changes resulting from retinal tissue pulling away from the underlying choroid describe a retinal detachment. This is a medical emergency characterized by sudden flashes of light, floaters, or a curtain-like shadow over the visual field. Open-angle glaucoma is a chronic, progressive condition rather than an acute mechanical separation of the retina. The pathology of glaucoma involves the optic nerve head rather than the total detachment of the neurosensory retinal layers from blood supply.
Choice B rationale
A cloudy lens that alters the passage of light describes a cataract. Cataracts lead to a gradual, painless blurring of vision and increased glare sensitivity as the proteins in the lens clump together. While both cataracts and glaucoma are common in aging populations, they have different mechanisms. Glaucoma specifically involves the drainage of aqueous humor and the resulting pressure on the optic nerve, whereas cataracts are strictly an opacity issue within the crystalline lens structure.
Choice C rationale
Open-angle glaucoma is characterized by a slow, progressive increase in intraocular pressure, typically ranging above the normal 10 to 21 mmHg. This pressure occurs because the aqueous humor cannot drain efficiently through the trabecular meshwork. Over time, the elevated pressure damages the optic nerve fibers, leading to a gradual loss of peripheral vision, often called tunnel vision. Because this happens slowly and painlessly, many patients remain asymptomatic until significant permanent visual loss occurs.
Choice D rationale
Blood vessels leaking fluid or blood under the retina is characteristic of wet macular degeneration. This condition involves neovascularization, where fragile new blood vessels grow and leak, causing rapid and severe central vision loss. In contrast, open-angle glaucoma affects the peripheral vision first and is related to fluid pressure within the anterior chamber of the eye rather than subretinal hemorrhaging or exudative processes in the macula. Glaucoma management focuses on lowering intraocular pressure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.