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
Insertion of a nasogastric tube is expected in a client with paralytic ileus to decompress the bowel by removing accumulated fluids and gas. Paralytic ileus is a non-mechanical obstruction of the bowel characterized by a lack of peristalsis, often occurring after abdominal surgery like an appendectomy. This decompression helps relieve abdominal distension, pain, and nausea, facilitating the return of bowel function.
Choice B rationale
Providing a bulk-forming agent, such as psyllium, is contraindicated in paralytic ileus. Bulk-forming agents work by increasing the volume of stool, which would exacerbate the obstruction and potentially cause further discomfort and complications in the absence of peristalsis. These agents are typically used to treat constipation by adding fiber to the diet and promoting bowel movements.
Choice C rationale
Administering an antacid, such as aluminum hydroxide or calcium carbonate, is not a primary intervention for paralytic ileus. Antacids work by neutralizing stomach acid and are used to treat conditions like heartburn and acid reflux. While a client with paralytic ileus might experience some gastric upset, the underlying issue is the lack of bowel motility, which antacids do not address.
Choice D rationale
Applying a truss is used to provide support for hernias, a condition unrelated to paralytic ileus following an appendectomy. A truss helps to keep the protruding tissue in place and reduce discomfort associated with the hernia. It does not address the underlying lack of bowel motility characteristic of paralytic ileus.
Correct Answer is B
Explanation
Choice A rationale
Decreased range of motion in a single joint, such as the right knee in a 77-year-old patient, can be attributed to various age-related changes like osteoarthritis or previous injury. While it warrants assessment, a recent loss of balance and fall is a more acute and potentially serious finding that requires immediate attention due to the increased risk of injury.
Choice B rationale
A history of recent loss of balance and a fall in an elderly patient is a significant finding that requires immediate further nursing assessment and intervention. Falls can lead to serious injuries, such as fractures, and may indicate underlying medical conditions, medication side effects, or environmental hazards that need to be addressed to prevent future falls.
Choice C rationale
Symmetric joint swelling of the fingers in a 77-year-old patient could be indicative of rheumatoid arthritis, an autoimmune condition more common in older adults. While it requires further assessment and diagnosis, it is generally a chronic condition and less immediately life-threatening than a recent fall.
Choice D rationale
A report of left hip aching when jogging in a 77-year-old patient could be related to musculoskeletal issues like arthritis or muscle strain. While it warrants assessment and management to improve comfort and mobility, it is less concerning in the immediate term compared to a recent loss of balance and fall, which poses a higher risk of acute injury. .
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