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
Nausea and vomiting are common side effects of morphine sulfate, an opioid analgesic administered via a PCA pump. An antiemetic medication directly addresses these symptoms and improves patient comfort.
Choice B rationale
Encouraging the use of an incentive spirometer is important for preventing postoperative respiratory complications, but it does not directly address the client's current nausea and vomiting.
Choice C rationale
Auscultating bowel sounds is important for assessing gastrointestinal function, but it does not provide immediate relief from nausea and vomiting. While changes in bowel sounds could indicate a problem, addressing the symptom with an antiemetic is the priority.
Choice D rationale
Inserting a nasogastric tube is an invasive procedure typically reserved for persistent vomiting, bowel obstruction, or gastric decompression. It is not the first-line intervention for nausea and vomiting related to opioid use.
Correct Answer is D
Explanation
Choice A rationale
Avoiding snacking between meals can actually worsen GERD symptoms for some individuals by allowing the stomach to become completely empty, which can then lead to increased acid production when the next meal is consumed. Smaller, more frequent meals are often recommended to maintain a more consistent level of gastric contents and reduce acid reflux.
Choice B rationale
Limiting foods high in fiber is generally not recommended for managing GERD. Fiber helps with gastric emptying and can prevent constipation, which can indirectly increase intra-abdominal pressure and potentially worsen reflux. A balanced diet with adequate fiber is usually encouraged.
Choice C rationale
Elevating the head of the bed by 6 to 8 inches, not 18 inches, is a recommended strategy to manage GERD. Gravity helps to keep stomach acid down in the stomach. An elevation of 18 inches might be too steep and uncomfortable for sleeping, potentially leading to other issues.
Choice D rationale
Avoiding eating 2 to 3 hours before bedtime is a crucial recommendation for managing GERD. Lying down shortly after eating can facilitate the backflow of stomach acid into the esophagus because gravity no longer assists in keeping the acid in the stomach. Allowing time for some gastric emptying before lying down can significantly reduce nighttime reflux symptoms. .
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