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 need something for the pain in my eye.
"My eye really itches, but I'm trying not to rub it.”.
"The bright light in this room is really bothering me.”. . . .
I can't stand it.”.
The Correct Answer is B
Choice A rationale
While it is understandable that a client with a patch on one eye after cataract surgery might express fear of falling due to altered depth perception, this comment reflects anxiety and a potential safety concern that the nurse should address with safety measures and reassurance, but it is not necessarily an unexpected complication requiring immediate reporting to the provider.
Choice B rationale
Reporting severe eye pain to the provider is crucial following cataract surgery. While some mild discomfort is expected, significant pain can indicate a potential complication such as increased intraocular pressure, infection (endophthalmitis), or corneal abrasion, all of which require prompt medical evaluation and intervention to prevent vision loss.
Choice C rationale
Mild itching after cataract surgery can be related to the healing process or the surgical dressing. Instructing the client not to rub the eye is appropriate to prevent infection or disruption of the surgical site. While the nurse should reinforce this instruction, the itching itself, without other signs of complications, does not necessarily warrant immediate reporting to the provider.
Choice D rationale
Sensitivity to bright light (photophobia) is a common occurrence after cataract surgery due to pupillary dilation during the procedure and the eye's adjustment to the new lens. Providing sunglasses or dimming the lights can help alleviate this discomfort. While the nurse should address this concern, it is a common and expected symptom that does not usually require immediate reporting to the provider unless it is severe or accompanied by other concerning symptoms. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Basal cell carcinoma is the most common type of skin cancer and often presents as a raised, flesh-colored or pearly white lesion with rolled borders and sometimes visible blood vessels (telangiectasia). Its slow growth and characteristic appearance align with the description provided.
Choice B rationale
Malignant melanoma is a more aggressive form of skin cancer that typically appears as an asymmetrical mole with irregular borders, uneven color (often shades of black, brown, red, white, or blue), and a diameter greater than 6 mm. It is less likely to present as a raised, flesh-colored lesion with pearly borders.
Choice C rationale
Actinic keratosis is a precancerous skin condition characterized by rough, scaly patches that develop on sun-exposed areas. These lesions are typically flat or slightly raised and can be red, tan, or flesh-colored. The description of pearly white borders does not typically fit actinic keratosis.
Choice D rationale
Squamous cell carcinoma is the second most common type of skin cancer and can appear as a firm, red nodule or a flat lesion with a scaly or crusted surface. While it can vary in appearance, the description of pearly white borders is more characteristic of basal cell carcinoma.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
· Initiate IV fluids – Contraindicated: While IV fluids might be helpful in some cases, excessive fluid administration could exacerbate certain conditions like heart failure or fluid overload. It would depend on the underlying cause of his symptoms.
· Administer aspirin for abdominal pain – Contraindicated: Aspirin can worsen gastrointestinal conditions, especially in someone with GERD. It can increase the risk of gastric irritation or even bleeding.
· Insert a nasogastric tube, attach to low suction – Contraindicated: While NG tube placement can be used for gastric decompression, it is generally not the first step in managing GERD or non-obstructive epigastric pain. This should only be considered if there is suspicion of an obstructive process.
· Initiate continuous ECG monitoring – Anticipated: Given his tachycardia, elevated blood pressure, and history of anxiety, monitoring his cardiac status would be appropriate to rule out cardiac involvement.
· Test stools for occult blood – Anticipated: Considering his long history of smoking and GERD, there is a risk of gastrointestinal bleeding, so checking for occult blood would be a reasonable precaution.
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