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 C
Explanation
Choice A Reason: Placing an ice pack on the lips if they swell is not an appropriate instruction for a client who is taking allopurinol, as it may indicate an allergic reaction or angioedema, which requires immediate medical attention.
Choice B Reason: Using an OTC antihistamine lotion if a rash develops is not an appropriate instruction for a client who is taking allopurinol, as it may indicate a serious skin reaction such as Stevens-Johnson syndrome or toxic epidermal necrolysis, which requires immediate medical attention.
Choice C Reason: Drinking at least 8 glasses of fluid every day is an appropriate instruction for a client who is taking allopurinol, as it helps to prevent kidney stones and flush out uric acid from the body.
Choice D Reason: Taking the medication on an empty stomach 2 hours before meals is not an appropriate instruction for a client who is taking allopurinol, as it may cause stomach upset or nausea. The medication should be taken after meals with plenty of water.
Correct Answer is B
Explanation
Choice A Reason: Swollen, painful joints are not a sign of Lyme disease in the early stage, but they may occur in the late stage, which can take months or years to develop.
Choice B Reason: An expanding circular rash, also known as erythema migrans, is a sign of Lyme disease in the early stage, which usually appears within 3 to 30 days after the tick bite. The rash may have a bull's-eye appearance and can spread up to 12 inches in diameter.
Choice C Reason: Decreased level of consciousness is not a sign of Lyme disease, but it may indicate other serious conditions such as meningitis, encephalitis, or stroke.
Choice D Reason: Necrosis at the site of the bite is not a sign of Lyme disease, but it may indicate a brown recluse spider bite, which can cause tissue damage and ulceration.
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