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 C
Explanation
Choice A rationale
Checking blood glucose levels for hypoglycemia once yearly is insufficient for a patient taking high doses of oral glucocorticoids for an extended period. Glucocorticoids can cause hyperglycemia by increasing gluconeogenesis and insulin resistance. Therefore, blood glucose monitoring should be more frequent, especially when initiating or adjusting the dosage. Normal fasting blood glucose levels are typically 70-99 mg/dL.
Choice B rationale
Limiting the intake of calcium-rich foods is incorrect advice for a patient on long-term glucocorticoid therapy. Glucocorticoids can decrease calcium absorption from the gut and increase bone resorption, leading to osteoporosis. Therefore, patients on these medications should be encouraged to maintain an adequate intake of calcium and vitamin D to help preserve bone density. Normal total serum calcium levels range from 8.6 to 10.2 mg/dL.
Choice C rationale
Monitoring for fractures over the next several months is an important instruction for a patient taking high doses of oral glucocorticoids long-term. Glucocorticoids increase the risk of osteoporosis and subsequent fractures, particularly vertebral compression fractures and hip fractures, due to their effects on bone metabolism. Regular monitoring and preventive measures are crucial.
Choice D rationale
Glucocorticoids do not boost immunity; instead, they suppress the immune system by inhibiting the production and function of various immune cells and inflammatory mediators. This immunosuppressive effect is why they are used to treat autoimmune diseases like rheumatoid arthritis, but it also increases the risk of infections.
Correct Answer is D
Explanation
Choice A rationale
Milk can temporarily buffer stomach acid, but it also stimulates acid production due to its fat and calcium content, potentially worsening GERD symptoms in the long run. Therefore, this is not a recommended instruction for managing GERD.
Choice B rationale
Sleeping on the left side may help reduce nighttime reflux in some individuals because the esophagus enters the stomach on the right side. This positioning can keep the lower esophageal sphincter above the level of gastric contents, reducing the likelihood of reflux.
Choice C rationale
Lying down shortly after eating can increase the risk of stomach acid refluxing into the esophagus. Gravity helps to keep stomach contents down when a person is upright. Waiting at least 2 to 3 hours after eating before going to bed is generally recommended to manage GERD.
Choice D rationale
Eating larger meals can increase gastric pressure and the volume of stomach contents, both of which can contribute to reflux. Consuming four to six smaller meals throughout the day can help reduce gastric distension and acid production after meals, thereby minimizing GERD symptoms.
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