Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye.
Which action should the nurse take?
Administer an antiemetic to prevent vomiting.
Report the complaint of eye pain to the surgeon.
Apply bilateral eye shields to reduce photosensitivity.
Begin postoperative prophylactic antibiotics.
The Correct Answer is B
Choice A rationale
While nausea and vomiting can be side effects of eye surgery, they are not typically associated with acute pain deep within the eye following laser trabeculoplasty. Therefore, administering an antiemetic would not address the client’s primary complaint.
Choice B rationale
Acute pain deep within the eye following laser trabeculoplasty is not a typical postoperative symptom and could indicate a complication such as increased intraocular pressure or inflammation. Therefore, the nurse should report this complaint to the surgeon immediately for further evaluation.
Choice C rationale
While eye shields can help reduce photosensitivity after eye surgery, they would not typically alleviate acute pain deep within the eye. Therefore, this action would not address the client’s primary complaint.
Choice D rationale
While prophylactic antibiotics can help prevent infection after eye surgery, they would not typically alleviate acute pain deep within the eye. Therefore, this action would not address the client’s primary complaint.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","F"]
Explanation
A.Bone misalignment- The nurse’s notes mention that the collarbone appears out of alignment on the left side. This could indicate a fracture or dislocation and should be investigated further.
B.Decreased range of motion- The client reports an inability to move his left arm. This could be due to the pain or a result of the injury and should be investigated further.
C.Left arm that is cool to touch- Decreased temperature in a limb can indicate poor circulation, which could be a result of the injury. This should be investigated further.
D.Swelling at the site of injury- Swelling and bruising are present on the client’s shoulder. This is a common sign of injury and should be investigated further.
E.Blood pressure of 136/90 mm Hg- While this blood pressure is not extremely high, it is on the higher end of normal. Given the client’s age and the stress of the situation, it would be worth monitoring.
F.Intense pain reported by client- The client reports a pain rating of 10 on a 0 to 10 scale in the left arm. This level of pain is concerning and should be addressed.
G.Oxygen saturation 95% on room air- While an oxygen saturation of 95% is within the normal range, given the client’s recent trauma and reported nausea, it would be prudent to monitor this closely.
Correct Answer is ["A","B"]
Explanation
Choice A rationale
A boggy fundus refers to an enlarged, soft, and tender uterus identified during physical examination. It is most commonly caused by uterine atony or adenomyosis. A boggy fundus 1 cm above the umbilicus requires immediate follow-up as it indicates that the uterus is not contracting properly after childbirth, which can lead to postpartum hemorrhage.
Choice B rationale
A fundus rotated to the right could indicate a distended bladder. This requires immediate follow-up as it can lead to urinary retention and other complications.
Choice C rationale
Voiding 200 mL of clear yellow urine is a normal finding and does not require immediate follow-up.
Choice D rationale
A blood pressure of 90/62 mm Hg is considered normal according to the American Heart Association. Therefore, it does not require immediate follow-up.
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