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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Administering an antipyretic to reduce the fever and notifying the primary health care provider are the priority actions. A rapid rise in temperature in a client with multiple myeloma receiving chemotherapy could indicate a serious infection, which requires prompt medical attention.

Choice B reason: Assessing the color and content of the urine specimen for urinalysis is important but is not the immediate priority. The rapid rise in temperature is a more urgent concern.

Choice C reason: Noting the consistency of respiratory secretions and obtaining a specimen for culture is important but not the immediate priority. The primary concern is addressing the fever and notifying the healthcare provider.

Choice D reason: Comparing prior vital signs and continuing to monitor every hour is necessary but not the immediate priority. Immediate action is required to address the fever and potential infection.

A. Hyperopia. B. Photophobia. C. Myopia. D. Accommodation.

Correct Answer is D

Explanation

Choice A reason: Hyperopia, also known as farsightedness, is a condition where distant objects can be seen more clearly than near objects. It is caused by the eyeball being too short or the cornea having too little curvature. In this scenario, the client's ability to adjust and focus on near and distant objects is not indicative of hyperopia.

Choice B reason: Photophobia is an increased sensitivity to light. It can be caused by various eye conditions, infections, or even migraines. The client's ability to focus on objects at different distances does not correlate with sensitivity to light.

Choice C reason: Myopia, or nearsightedness, is the opposite of hyperopia. Individuals with myopia can see near objects clearly but have difficulty focusing on distant objects. The client's ability to focus on both near and far objects rules out myopia.

Choice D reason: Accommodation is the process by which the eye adjusts its focus from near to distant objects (or vice versa). This involves changes in the shape of the lens, controlled by the ciliary muscles. The client's ability to focus on objects at varying distances correctly describes the accommodation process, making it the appropriate answer.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with multiple myeloma receiving chemotherapy has a temperature of 102.2 degrees Fahrenheit. The temperature was 99.2 degrees Fahrenheit six hours ago. The PRIORITY nursing intervention is to:

Correct Answer is A

Explanation

The nurse is assessing a client's eyes and notes that when the client looks at a near object, the pupil constricts, but when the client looks at an object in the distance, the pupil dilates. The nurse should identify this finding as which condition?

Correct Answer is D

Explanation

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