A nurse in the ambulatory care unit is caring for a client after cataract extraction. The client suddenly complains of severe pain in the affected eye unrelieved by pain medications. Which of the following actions should the nurse take first?
Tell the client that this is to be expected after surgery.
Place the client in a supine position.
Document the findings.
Notify the surgeon.
The Correct Answer is D
Choice A Reason: Telling the client that this is to be expected after surgery is not the first action that the nurse should take, as it may indicate a complication such as increased intraocular pressure, hemorrhage, or infection.
Choice B Reason: Placing the client in a supine position is not the first action that the nurse should take, as it may worsen the pain and increase intraocular pressure.
Choice C Reason: Documenting the findings is not the first action that the nurse should take, as it may delay the intervention and outcome.
Choice D Reason: Notifying the surgeon is the first action that the nurse should take, as it indicates that the client needs immediate evaluation and treatment to prevent vision loss or permanent damage to the eye.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A Reason: Weight gain is a common finding in hypothyroidism, as the decreased thyroid hormone level causes the metabolism to slow down and the body to store more fat.
Choice B Reason: Constipation is a common finding in hypothyroidism, as the decreased thyroid hormone level causes the gastrointestinal motility to decrease and the stools to become hard and dry.
Choice C Reason: Rapid pulse is not a common finding in hypothyroidism, but it may indicate other conditions such as hyperthyroidism or anxiety.
Choice D Reason: Decreased energy is a common finding in hypothyroidism, as the decreased thyroid hormone level causes the body to feel tired and sluggish.
Choice E Reason: Hypertension is not a common finding in hypothyroidism, but it may indicate other conditions such as renal disease or cardiovascular disease.
Correct Answer is C
Explanation
Choice A Reason: Cold skin is not a common finding in hyperthyroidism, but it may indicate hypothyroidism or other conditions such as hypothermia or shock.
Choice B Reason: Weight gain is not a common finding in hyperthyroidism, but it may indicate hypothyroidism or other conditions such as Cushing's syndrome or edema.
Choice C Reason: Tachycardia is a common finding in hyperthyroidism, as the increased thyroid hormone level causes the heart rate and cardiac output to increase.
Choice D Reason: Anorexia is not a common finding in hyperthyroidism, but it may indicate other conditions such as depression, infection, or cancer.
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