The nurse is caring for a client who has undergone a cataract extraction and during the early postoperative period is complaining of nausea and severe eye pain over the operative site. What should be the initial nursing action?

Turn the client onto their operative side.

Administer the prescribed pain medication and antiemetic.

Call the surgeon.

Reassure the client that this is normal.

Answer and Explanation

The Correct Answer is B

A. Turning the client onto their operative side could increase pressure on the eye and is not an appropriate first action.
B. Administering prescribed pain medication and antiemetic is essential to address the client's severe pain and nausea, which are priority concerns in the postoperative period.
C. While it may be necessary to notify the surgeon if symptoms persist, the immediate priority is to alleviate the client's discomfort.
D. Reassuring the client that these symptoms are normal is misleading; severe pain and nausea postoperatively should be addressed promptly.

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Correct Answer is C

Explanation

A. Diplopia is a concerning symptom but does not indicate immediate deterioration in neurological status like a change in GCS does.
B. Ataxia is also significant but is less acute than a drop in GCS score.
C. A change in the Glasgow Coma Scale score from 13 to 11 indicates a worsening level of consciousness and necessitates immediate reporting, as it may suggest increased intracranial pressure or other complications.
D. A decrease in heart rate from 76 to 69 bpm is not significant enough in the context of TBI to warrant immediate reporting, as it remains within a normal range.

A. Major effects on the metabolism of almost all organs of the body B. Fluid and electrolyte balance C. Regulate carbohydrate and protein metabolism D. The release of the ACTH from the anterior lobe of the pituitary gland

Correct Answer is B

Explanation

A. While hormones from the adrenal cortex do influence various metabolic processes, mineralocorticoids primarily focus on fluid and electrolyte balance rather than having major effects on all organs' metabolism.
B. Mineralocorticoids, such as aldosterone, play a crucial role in regulating fluid and electrolyte balance by promoting sodium retention and potassium excretion in the kidneys.
C. Regulation of carbohydrate and protein metabolism is mainly the function of glucocorticoids, not mineralocorticoids.
D. The release of ACTH is regulated by corticotropin-releasing hormone (CRH) from the hypothalamus, not directly influenced by mineralocorticoids.

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The nurse is caring for a client who has undergone a cataract extraction and during the early postoperative period is complaining of nausea and severe eye pain over the operative site. What should be the initial nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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