A nurse is caring for a client following cataract surgery. Which comment from the client should the nurse report to the client's health care provider IMMEDIATELY?
The bright light in this room is really bothering me
It's hard to see with a patch on one eye, I'm afraid of falling
My eye really itches but I'm trying not to rub it
I need something for the pain in my eye, I can't stand it
The Correct Answer is D
Choice A reason: Bright light sensitivity is a common side effect following cataract surgery and can be managed with appropriate measures such as wearing sunglasses. It does not necessarily indicate a complication requiring immediate reporting.
Choice B reason: Difficulty seeing with a patch on one eye and fear of falling are valid concerns, but they do not necessarily indicate an immediate complication that requires urgent reporting to the healthcare provider.
Choice C reason: Eye itching is common after cataract surgery, and the client should be advised not to rub the eye to prevent infection or damage. This comment does not indicate a severe complication that needs immediate reporting.
Choice D reason: Severe eye pain that the client cannot stand is a potential sign of a serious complication, such as increased intraocular pressure, infection, or other postoperative issues. This requires immediate attention from the healthcare provider to prevent further complications and ensure the client's safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Hyperkalemia is a common finding in the oliguric phase of acute kidney injury due to reduced excretion of potassium by the kidneys. This electrolyte imbalance can have serious cardiac effects and should be expected and monitored in these patients.
Choice B reason: An increased glomerular filtration rate (GFR) would not be expected in the oliguric phase of acute kidney injury. Typically, GFR is decreased due to reduced kidney function during this phase.
Choice C reason: Decreased creatinine levels are not expected in acute kidney injury. Creatinine levels usually increase as kidney function declines and the body cannot adequately filter waste.
Choice D reason: Hypovolemia is not typically expected in the oliguric phase of acute kidney injury, as oliguria (reduced urine output) often indicates fluid retention rather than fluid loss.
Correct Answer is C
Explanation
Choice A reason: Mild headaches are not typically associated with increased intraocular pressure. While headaches can accompany eye conditions, they are not as common or specific as severe eye pain in this context.
Choice B reason: Cloudiness that worsens at night could be related to cataracts or other eye conditions but is not a specific manifestation of increased intraocular pressure. Severe eye pain is a more direct indicator of conditions like acute angle-closure glaucoma.
Choice C reason: Severe eye pain is a significant clinical manifestation of increased intraocular pressure, such as in acute angle-closure glaucoma. This condition can lead to sudden, severe eye pain due to the rapid rise in intraocular pressure, which can damage the optic nerve if not treated promptly.
Choice D reason: Mild eye pain may occur in various minor eye conditions but is not as indicative of serious issues like increased intraocular pressure. Severe eye pain is more concerning and requires immediate assessment and intervention.
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