A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?
"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."
"The bright light in this room is really bothering me."
"I need something for the pain in my eye. I can't stand it."
The Correct Answer is D
Choice A reason: This is incorrect because this comment does not require reporting to the client's provider. It is normal to have reduced vision and an increased risk of falling with a patch on one eye after cataract surgery. The nurse should reassure the client, provide assistance with mobility, and educate the client on safety measures.
Choice B reason: This is incorrect because this comment does not require reporting to the client's provider. It is normal to have some itching and discomfort in the eye after cataract surgery. The nurse should commend the client for not rubbing the eye, as this can cause infection or damage to the surgical site. The nurse should also administer anti-inflammatory eye drops as prescribed and instruct the client on how to apply them.
Choice C reason: This is incorrect because this comment does not require reporting to the client's provider. It is normal to have increased sensitivity to light in the eye after cataract surgery. The nurse should dim the lights in the room, provide sunglasses or a shield for the eye, and educate the client on how to protect the eye from bright light.
Choice D reason: This is the correct answer because this comment requires reporting to the client's provider. Severe pain in the eye after cataract surgery can indicate a complication such as infection, inflammation, bleeding, or increased intraocular pressure. The nurse should assess the eye for signs of redness, swelling, discharge, or bleeding, and report the findings and the pain level to the provider. The nurse should also administer analgesics as prescribed and monitor the pain relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because administering medications and electrolytes is not the primary purpose of inserting a nasogastric tube for a client with acute peritonitis. Medications and electrolytes can be given through other routes, such as IV or oral.
Choice B Reason: This is incorrect because dilating the stomach as a presurgical preparation is not a relevant Reason for inserting a nasogastric tube for a client with acute peritonitis. Dilating the stomach may be done before some types of gastric surgery, but it does not apply to peritonitis.
Choice C Reason: This is incorrect because stating that you will not be able to eat for several days is not an adequate explanation for inserting a nasogastric tube for a client with acute peritonitis. This statement does not address the rationale or the benefits of the procedure. It may also cause anxiety and resentment in the client.
Choice D Reason: This is the correct choice because removing secretions and decompressing the stomach is the main Reason for inserting a nasogastric tube for a client with acute peritonitis. Peritonitis is an inflammation of the peritoneum, the membrane that lines the abdominal cavity. It can cause abdominal distension, pain, nausea, and vomiting. A nasogastric tube can suction out the gastric contents and reduce the pressure and irritation in the abdomen.
Correct Answer is A
Explanation
Choice A reason: This is correct because hearing loss is the most common complaint associated with a problem involving the inner ear. The inner ear consists of the cochlea, which is the organ of hearing, and the vestibular system, which is the organ of balance. The inner ear converts sound waves into nerve impulses that are sent to the brain. Any damage or dysfunction of the inner ear can impair hearing and cause hearing loss.
Choice B reason: This is incorrect because tinnitus is not the most common complaint associated with a problem involving the inner ear, but rather a symptom that can occur with various ear problems. Tinnitus is a ringing, buzzing, or hissing sound in the ears that is not caused by an external source. Tinnitus can be caused by exposure to loud noise, ear infections, earwax buildup, aging, or certain medications, but it is not specific to the inner ear.
Choice C reason: This is incorrect because pruritus is not a complaint associated with a problem involving the inner ear, but rather a complaint associated with a problem involving the outer ear. Pruritus is itching of the skin that can be caused by dryness, irritation, infection, or allergy. Pruritus can affect the outer ear, which is the visible part of the ear that collects and directs sound waves into the ear canal, but it has no relation to the inner ear.
Choice D reason: This is incorrect because muffled sounds are not a complaint associated with a problem involving the inner ear, but rather a complaint associated with a problem involving the middle ear. Muffled sounds are sounds that are unclear or distorted due to reduced sound transmission or perception. Muffled sounds can be caused by fluid buildup, inflammation, infection, or perforation of the eardrum in the middle ear, which is the air-filled space between the eardrum and the inner ear that contains three tiny bones that amplify sound vibrations.
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