c. Begin continuous cardiac monitoring.
d. Prepare to give sympathomimetic drugs.
e. Obtain a prescription for patient restraints.
ANS: A, B, C
Cooling can produce dysrhythmias, so thepatient‘s heart rhythm would be continuously
monitored, and dysrhythmias treated if necessary. Bladder catheterization and endotracheal
intubation are needed during cooling. Sympathomimetic drugs tend to stimulate theheart and
increase therisk for fatal dysrhythmias such as ventricular fibrillation. Patients receiving
therapeutic hypothermia are comatose, so restraints are not indicated.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Planning
MSC:NCLEX: Physiological Integrity
2. The emergency department (ED) nurse is starting targeted temperature
management/therapeutic hypothermia in a patient who has been resuscitated after a cardiac
arrest. Which actions in thehypothermia protocol can be delegated to an experienced licensed
practical/vocational nurse (LPN/VN)? (Select all that apply.)
a. Evaluate changes in heart rhythm.
b. Insert a urinary catheter to drainage.
c. Assess neurologic status every 2 hours.
d. Place cooling blankets above and below patient.
e. Attach rectal temperature probe to cooling blanket control panel.
ANS: B, D, E
Experienced LPN/VNs have theeducation and scope of practice to implement hypothermia
measures (e.g., cooling blanket, temperature probe) and insert a urinary catheter under
thesupervision of a registered nurse (RN). Assessment of neurologic status and evaluating
changes in heart rhythm require RN-level education and scope of practice.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Planning
MSC:NCLEX: Safe and Effective Care Environment
Chapter 22: Assessment and Management: Visual Problems
Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
MULTIPLE CHOICE
1. The nurse is performing an eye examination on a 76-yr-old patient. Which finding indicates
that thenurse would refer thepatient for a more extensive assessment?
a. The patient‘s sclerae are light yellow.
b. The patient reports persistent photophobia.
c. The pupil recovers slowly after responding to a bright light.
d. There is a whitish gray ring encircling theperiphery of theiris.
ANS: B
Photophobia is not a normally occurring change with aging and would require further
assessment. theother assessment data are common gerontologic differences in assessment and
would not be unusual in a 76-yr-old patient.
DIF:CognitiveLevel: Apply (Application)
TOP: NursingProcess: Assessment MSC:NCLEX: Physiological Integrity
2. Which finding by thenurse performing an eye examination indicates that thepatient has
normal accommodation?
a. After covering one eye for 1 minute, thepupil constricts as thecover is removed.
b. Shining a light into thepatient‘s eye causes pupil constriction in theopposite eye.
c. A blink reaction occurs after touching thepatient‘s pupil with a piece of sterile
cotton.
d. The pupils constrict while fixating on an object being moved toward thepatient‘s
eyes.
ANS: D
Accommodation is defined as theability of thelens to adjust to various distances. thepupils
constrict while fixating on an object that is being moved from far away to near theeyes.
theother responses may also be elicited as part of theeye examination, but they do not indicate
accommodation.
DIF:CognitiveLevel: Apply (Application)
TOP: NursingProcess: Assessment MSC:NCLEX: Health Promotion and Maintenance
3. Which assessment finding alerts thenurse to provide patient teaching about cataract
development?
a. Unequal pupil size
b. Glare at night
c. Loss of peripheral vision
d. History of hyperthyroidism
ANS: A
Classic signs of cataracts include blurred vision and glare that worsens at night. Thyroid
problems are a major cause of exophthalmos. Unequal pupil is not indicative of cataracts.
Loss of peripheral vision is a sign of glaucoma.
DIF:CognitiveLevel: Apply (Application)
TOP: NursingProcess: Assessment MSC:NCLEX: Health Promotion and Maintenance
4. Assessment of a patient‘s visual acuity reveals that theleft eye can see at 20 feet what a person
with normal vision can see at 50 feet and theright eye can see at 20 feet what a person with
normal vision can see at 40 feet. Which finding would thenurse record?
a. Left eye 20/50; Right eye 20/40
b. Both eyes 20/40; Left eye 50/20
c. Right eye 20/40; Left eye 20/50
d. Both eyes 40/20; Right eye 50/20
ANS: A
When documenting visual acuity, thefirst number indicates thestandard (for normal vision) of
20 feet and thesecond number indicates theline that thepatient is able to read when standing 20
feet from theSnellen chart. For this patient, that is Left eye 20/50; Right eye 20/40.
DIF:CognitiveLevel: Understand (Comprehension)
TOP: NursingProcess: Assessment MSC:NCLEX: Health Promotion and Maintenance
5. A 65-yr-old patient is being evaluated for glaucoma. Which information from thepatient has
implications for thepatient‘s interprofessional treatment plan?
a. ―I take metoprolol (Lopressor) for angina.‖
b. ―I take aspirin when I have a sinus headache.‖
c. ―I have had frequent episodes of conjunctivitis.‖
d. ―I have not had an eye examination for 10 years.‖
ANS: A
It is important to note whether thepatient takes any -adrenergic blockers because this
classification of medications is also used to treat glaucoma, and there may be an increase in
adverse effects. theuse of aspirin does not increase intraocular pressure and is safe for patients
with glaucoma. Although older patients should have yearly eye examinations, treatment will
not be affected by the10-year gap in eye care. Conjunctivitis does not increase therisk for
glaucoma.
DIF:CognitiveLevel: Apply (Application)
TOP: NursingProcess: Assessment MSC:NCLEX: Physiological Integrity
6. The nurse is testing thevisual acuity of a patient in theoutpatient clinic. Which instructions
would thenurse give for this test?
a. ―Stand 20 feet away from thewall chart.‖
b. ―Look at an object far away and then near to you.‖
c. ―Follow theexaminer‘s finger with your eyes only.‖
d. ―Look straight ahead while I check your eyes with a light.‖
ANS: A
When theSnellen chart is used to check visual acuity, thepatient should stand 20 ft away.
Accommodation is tested by looking at an object at both near and far distances. Shining a pen
light into theeyes tests for pupil response. Following theexaminer‘s fingers with theeyes tests
extraocular movements.
DIF:CognitiveLevel: Apply (Application)
TOP: NursingProcess: Assessment MSC:NCLEX: Health Promotion and Maintenance
7. A patient who underwent eye surgery must wear an eye patch until thescheduled postoperative
clinic visit. Which patient problem will thenurse address in theplan of care?
a. Risk for injury
b. Difficulty coping
c. Negative self-image
d. Health maintenance alteration
ANS: A
The loss of stereoscopic vision created by theeye patch impairs thepatient‘s ability to see in
three dimensions and to judge distances. This increases therisk for falls and other injuries.
There is no evidence for inability to manage health, negative self-image, or difficulty coping.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Diagnosis
MSC:NCLEX: Safe and Effective Care Environment
8. Which information would thenurse provide to thepatient scheduled for refractometry?
a. ―You should not take any of your eye medicines before theexamination.‖
b. ―It will be difficult to focus your vision for a few hours after theexamination.‖
c. ―The doctor will shine a bright light into your eye during theexamination.‖
d. ―The surface of your eye will be numb while thedoctor does theexamination.‖
ANS: B
The pupils are dilated using cycloplegic medications during refractometry. This effect will last
several hours and causes photophobia and difficulty focusing vision. theother teaching would
not be appropriate for a patient who was having refractometry.
DIF:CognitiveLevel: Apply (Application)
TOP: NursingProcess: Implementation MSC:NCLEX: Physiological Integrity
9. The nurse is assessing a 65-yr-old patient for presbyopia. Which instruction would thenurse
give thepatient before thetest?
a. ―Hold this card and read theprint out loud.‖
b. ―Cover one eye while reading thewall chart.‖
c. ―You‘ll feel a short burst of air directed at your eyeball.‖
d. ―A light will be used to look for a change in your pupils.‖
ANS: A
The Jaeger card is used to assess near vision problems and presbyopia in persons older than
40 years of age. thecard should be held 14 inches away from eyes while thepatient reads
words in various print sizes. Using a penlight to determine pupil change is testing pupil
response. A short burst of air may be used to test intraocular pressure. Covering one eye at a
time while reading a wall chart at 20 feet describes theSnellen test.
DIF:CognitiveLevel: Apply (Application)
TOP: NursingProcess: Assessment MSC:NCLEX: Health Promotion and Maintenance
10. Which instruction would thenurse give thepatient before fluorescein angiography?
a. Hold a card and fixate on thecenter dot.
b. Report any burning or pain at theIV site.
c. Remain still while thecornea is anesthetized.
d. Let theexaminer know when images appear clear.
ANS: B
Fluorescein angiography involves injecting IV dye. If extravasation occurs, fluorescein is
toxic to thetissues. Teach thepatient to report any signs of extravasation, such as pain or
burning. thenurse should closely monitor theIV site as well. thecornea is anesthetized during
ultrasonography. Refractometry involves measuring visual acuity and asking thepatient to
choose lenses that are thesharpest; it is a painless test. theAmsler grid test involves using a
hand-held card with grid lines. thepatient fixates on thecenter dot and records any
abnormalities of thegrid lines.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Planning
MSC:NCLEX: Physiological Integrity
11. Which action can thenurse working in theemergency department delegate to experienced
assistive personnel (AP)?
a. Ask a patient with decreased visual acuity about medications taken at home.
b. Perform Snellen testing of visual acuity for a patient with a history of cataracts.
c. Obtain information from a patient about any history of childhood ear infections.
d. Inspect a patient‘s external ear for redness, swelling, or presence of skin lesions.
ANS: B
The Snellen test does not require nursing judgment and is appropriate to delegate to AP who
have been trained to perform it. History taking about infection or medications and assessment
are actions that require critical thinking and should be done by theRN.
DIF:CognitiveLevel: Apply (Application)
TOP: NursingProcess: Assessment MSC:NCLEX: Safe and Effective Care Environment
12. The nurse working in theclinic receives telephone calls from several patients who want
appointments as soon as possible. Which patient should be seen first?
a. 71-yr-old who has noticed increasing loss of peripheral vision
b. 74-yr-old who has difficulty seeing well enough to drive at night
c. 60-yr-old who is reporting dry eyes with decreased tear formation
d. 64-yr-old who states that it is becoming difficult to read news print
ANS: A
Increasing loss of peripheral vision is characteristic of glaucoma, and thepatient should be
scheduled for an examination as soon as possible. theother patients have symptoms commonly
associated with aging: presbyopia, decreased tear formation, and impaired night vision.
DIF:CognitiveLevel: Analyze (Analysis) TOP: NursingProcess: Planning
MSC:NCLEX: Safe and Effective Care Environment
13. Which assessment would thenurse make to evaluate theeffectiveness of treatment for
thepatient‘s myopia and presbyopia?
a. Eye muscle strength
b. Near and distant vision
c. Cloudiness in theeye lenses
d. Intraocular pressure changes
ANS: B
Bifocal or progressive lenses are prescribed to correct thepatient‘s near and distant vision.
thenurse may assess for cloudiness of thelenses, increased intraocular pressure, and eye
movement, but these data do not evaluate whether thepatient‘s bifocals are effective.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Evaluation
MSC:NCLEX: Physiological Integrity
14. Which instruction would thenurse give to a patient with recurrent staphylococcal and
seborrheic blepharitis?
a. Irrigate theeyes with saline solution.
b. Schedule an appointment for eye surgery.
c. Use a gentle baby shampoo to clean theeyelids.
d. Apply cool compresses to theeyes three times daily.
ANS: C
Baby shampoo is used to soften and remove crusts associated with blepharitis. theother
interventions are not used in treating this disorder.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Planning
MSC:NCLEX: Physiological Integrity
15. Which technique is thesafest for thenurse to use when assisting a blind patient to ambulate to
thebathroom?
a. Lead thepatient slowly to thebathroom, holding on to thepatient‘s arm.
b. Stay beside thepatient and describe any obstacles on thepath to thebathroom.
c. Walk slightly ahead of thepatient, allowing thepatient to hold thenurse‘s elbow.
d. Have thepatient place a hand on thenurse‘s shoulder and guide thepatient forward.
ANS: C
When using thesighted-guide technique, thenurse walks slightly in front and to theside of
thepatient and has thepatient hold thenurse‘s elbow. theother techniques are not as safe in
assisting a blind patient.
DIF:CognitiveLevel: Apply (Application)
TOP: NursingProcess: Implementation MSC:NCLEX: Safe and Effective Care Environment
16. Which instruction about preventing further infection would thenurse give to a patient with
repeated sty (hordeolum)?
a. Apply cold compresses.
b. Discard all used eye cosmetics.
c. Wash theeyebrows with an antiseborrheic shampoo.
d. Be examined for sexually transmitted infections (STIs).
ANS: B
A sty (hordeolum) is commonly caused by Staphylococcus aureus, which may be present in
cosmetics that thepatient is using. Warm compresses are recommended to treat a sty.
Antiseborrheic shampoos are recommended for seborrheic blepharitis. Patients with adult
inclusion conjunctivitis, which is caused by Chlamydia trachomatis, would be referred for
STI testing.
DIF:CognitiveLevel: Apply (Application)
TOP: NursingProcess: Implementation MSC:NCLEX: Physiological Integrity
17. Which instruction would thenurse include in a teaching plan for a patient with herpes simplex
keratitis in one eye?
a. Wash hands frequently and avoid touching theeyes.
b. Apply antibacterial drops to theeye several times daily.
c. Apply a new occlusive dressing to theaffected eye at bedtime.
d. Use corticosteroid ophthalmic ointment to decrease inflammation.
ANS: A
The best way to avoid thespread of infection from one eye to another is to avoid rubbing or
touching theeyes and to use careful hand washing when touching theeyes is unavoidable.
Occlusive dressings are not used for herpes keratitis. Herpes simplex is a virus, and
antibacterial drops will not be prescribed. Topical corticosteroids are immunosuppressive and
typically are not ordered because they can contribute to a longer course of infection and more
complications.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Planning
MSC:NCLEX: Physiological Integrity
18. Which information would thenurse plan to teach when caring for a patient whose vision is
corrected to 20/200?
a. Accessing recorded books
b. Using a white cane safely
c. Finding Braille instruction
d. Obtaining a hand-held magnifier
ANS: D
Various types of magnifiers can enhance impaired vision enough to allow theperformance of
many tasks and activities of daily living. Audio books, Braille instruction, and canes usually
are reserved for patients with little or no functional vision.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Planning
MSC:NCLEX: Physiological Integrity
19. The nurse is caring for a patient diagnosed with adult inclusion conjunctivitis (AIC) caused by
C. trachomatis. Which action would thenurse include in theplan of care?
a. Applying topical corticosteroids to decrease inflammation
b. Discussing theneed for sexually transmitted infection testing
c. Educating about theuse of antiviral eyedrops to treat theinfection
d. Assisting with applying for community visual rehabilitation services
ANS: B
Patients with AIC have a high risk for concurrent genital Chlamydia infection and would be
referred for sexually transmitted infection testing. AIC is treated with antibiotics. Antiviral
and corticosteroid medications are not appropriate therapies. Although some types of
Chlamydia infection do cause blindness, AIC does not lead to blindness, so referral for visual
rehabilitation is not appropriate.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Planning
MSC:NCLEX: Physiological Integrity
20. Which topic will thenurse teach after a patient has had outpatient cataract surgery and lens
implantation?
a. Use of oral opioids for pain control
b. Administration of corticosteroid drops
c. Need for bed rest for 1 to 2 days after thesurgery
d. Importance of coughing and deep breathing exercises
ANS: B
Antibiotic and corticosteroid eyedrops are commonly prescribed after cataract surgery.
thepatient should be able to administer them using safe technique. Pain is not expected after
cataract surgery, and opioids will not be needed. Coughing and deep breathing exercises are
not needed because a general anesthetic agent is not used. There is no bed rest restriction after
cataract surgery.
DIF:CognitiveLevel: Apply (Application)
TOP: NursingProcess: Implementation MSC:NCLEX: Physiological Integrity
21. In reviewing a patient‘s medical record, thenurse notes that thelast eye examination revealed
an intraocular pressure of 28 mm Hg. Which assessment at would thenurse plan to make?
a. Visual acuity
b. Pupil reaction
c. Color perception
d. Peripheral vision
ANS: D
The patient‘s increased intraocular pressure indicates glaucoma, which decreases peripheral
vision. Because central visual acuity is unchanged by glaucoma, assessment of visual acuity
could be normal even if thepatient has worsening glaucoma. Color perception and pupil
reaction to light are not affected by glaucoma.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Planning
MSC:NCLEX: Physiological Integrity
22. A patient with a retinal detachment had a pneumatic retinopexy procedure. Which information
would thenurse include in thedischarge teaching plan?
a. The use of eye patches to reduce movement of theoperative eye
b. The need to wear dark glasses to protect theeyes from bright light
c. The purpose of maintaining thehead resting in a prescribed position
d. The procedure for dressing changes when theeye dressing is saturated
ANS: C
Following pneumatic retinopexy, thepatient will need to position thehead so theair bubble
remains in contact with theretinal tear. Dark lenses and bilateral eye patches are not required
after this procedure. Saturation of any eye dressings would not be expected following this
procedure.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Planning
MSC:NCLEX: Physiological Integrity
23. A patient with age-related macular degeneration (AMD) has just had photodynamic therapy.
Which statement by thepatient indicates that thedischarge teaching has been effective?
a. ―I will use drops to keep my pupils dilated until my appointment.‖
b. ―I will need to use brighter lights to read for at least thenext week.‖
c. ―I will not use facial lotions near my eyes during therecovery period.‖
d. ―I will cover up with long-sleeved shirts and pants for thenext 5 days.‖
ANS: D
The photosensitizing drug used for photodynamic therapy is activated by exposure to bright
light and can cause burns in areas exposed to light for 5 days after thetreatment. There are no
restrictions on theuse of facial lotions, medications to keep thepupils dilated would not be
appropriate, and bright lights would increase therisk for damage caused by thetreatment.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Evaluation
MSC:NCLEX: Physiological Integrity
24. How would thenurse evaluate a patient for improvement after treatment of primary open-angle
glaucoma (POAG)?
a. Ask thepatient about blurred vision.
b. Assess for changes in thepatient‘s visual field.
c. Ask thepatient to rate thepain using a 0 to 10 scale.
d. Assess thepatient‘s depth perception when climbing stairs.
ANS: B
POAG develops slowly and without symptoms except for a gradual loss of visual fields.
Acute closed-angle glaucoma may present with excruciating pain, colored halos, and blurred
vision. Problems with depth perception are not associated with POAG.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Evaluation
MSC:NCLEX: Physiological Integrity
25. Which patient arriving at theurgent care center would thenurse assess first?
a. Patient who is reporting that theleft eyelid has just started to droop
b. Patient with acute right eye pain that began while using power tools
c. Patient with purulent left eye discharge and conjunctival inflammation
d. Patient who has redness, crusting, and swelling along thelower right lid margin
ANS: B
The history and symptoms suggest eye trauma with a possible penetrating injury. Blindness
may occur unless thepatient is assessed and treated rapidly. theother patients should be treated
as soon as possible, but do not have clinical manifestations that indicate any acute risk for
vision or hearing loss.
DIF:CognitiveLevel: Analyze (Analysis) TOP: NursingProcess: Planning
MSC:NCLEX: Safe and Effective Care Environment
26. A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells
thenurse that theeyedrops cause eye burning and visual blurriness after administration. Which
response would thenurse provide?
a. ―Those symptoms may indicate a need for a change in dosage of theeyedrops.‖
b. ―The drops are uncomfortable, but using them can help to retain your vision.‖
c. ―These are normal side effects of thedrug, which will go away over time.‖
d. ―Notify your health care provider so that different eyedrops can be prescribed.‖
ANS: B
Patients would be taught that eye discomfort and visual blurring are expected side effects of
theophthalmic drops but that thedrops must be used to prevent further visual-field loss.
thetemporary burning and visual blurriness might not lessen with ongoing use and do not
indicate a need for a dosage or medication change.
DIF:CognitiveLevel: Apply (Application)
TOP: NursingProcess: Implementation MSC:NCLEX: Physiological Integrity
27. Which statement by a patient with bacterial conjunctivitis indicates a need for further
teaching?
a. ―I will wash my hands often during theday.‖
b. ―I will remove my contact lenses at bedtime.‖
c. ―I will not share towels with my friends or family.‖
d. ―I will monitor my family for eye redness or drainage.‖
ANS: B
Contact lenses should not be used when patients have conjunctivitis because they can further
irritate theconjunctiva. Hand washing is themajor means to prevent thespread of
conjunctivitis. Infection may be spread by sharing towels or other contact. It is common for
bacterial conjunctivitis to spread through a family or other group in close contact.
DIF:CognitiveLevel: Apply (Application)
TOP: NursingProcess: Implementation MSC:NCLEX: Physiological Integrity
28. The nurse at theoutpatient surgery unit obtains thefollowing information about a patient who
is scheduled for cataract extraction and implantation of an intraocular lens. Which information
would thenurse report to thehealth care provider before theprocedure?
a. The patient has had blurred vision for 3 years.
b. A family member will drive thepatient home.
c. The patient takes antihypertensive medications.
d. The patient reports nausea with general anesthesia.
ANS: C
Mydriatic medications used for pupil dilation are sympathetic nervous system stimulants and
may increase heart rate and blood pressure. Using punctal occlusion when administering
themydriatic and monitoring of blood pressure are indicated for this patient. Blurred vision is
an expected finding with cataracts. Patients are instructed not to drive after surgery due to
thelimited vision with an eye patch in place. Cataract extraction and intraocular lens
implantation are done using local anesthesia.
DIF:CognitiveLevel: Apply (Application)
TOP: NursingProcess: Assessment MSC:NCLEX: Physiological Integrity
29. The nurse learns that a newly admitted patient has functional blindness and that thespouse has
cared for thepatient for many years. Which action would thenurse take during theinitial
assessment?
a. Obtain more information about thecause of thepatient‘s vision loss.
b. Obtain information from thespouse about thepatient‘s special needs.
c. Make eye contact with thepatient and ask about any need for assistance.
d. Perform an evaluation of thepatient‘s visual acuity using a Snellen chart.
ANS: C
Making eye contact with a partially sighted patient allows thepatient to hear thenurse more
easily and allows thenurse to assess thepatient‘s facial expressions. thepatient (rather than
thespouse) would be asked first about any need for assistance. theinformation about thecause
of thevision loss and assessment of thepatient‘s visual acuity are not priorities during theinitial
assessment.
DIF:CognitiveLevel: Analyze (Analysis)
TOP: NursingProcess: Assessment MSC:NCLEX: Physiological Integrity
30. Which action could theregistered nurse (RN) who is working in theclinic delegate to a
licensed practical/vocational nurse (LPN/VN)?
a. Evaluate a patient‘s ability to administer eyedrops.
b. Check a patient‘s visual acuity using a Snellen chart.
c. Inspect a patient‘s retina with an ophthalmoscope.
d. Teach a patient about medications to treat glaucoma.
ANS: B
Using standardized screening tests such as a Snellen chart to test visual acuity is included in
LPN education and scope of practice. Evaluation, assessment, and patient teaching are higher
level skills that require RN education and scope of practice.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Planning
MSC:NCLEX: Safe and Effective Care Environment
31. The occupational health nurse is caring for an employee who reports bilateral eye pain after a
cleaning solution splashed into theemployee‘s eyes. Which action will thenurse take?
a. Apply cool compresses.
b. Flush theeyes with saline.
c. Apply antiseptic ophthalmic ointment to theeyes.
d. Cover theeyes with dry sterile patches and shields.
ANS: B
In thecase of chemical exposure, thenurse should begin treatment by flushing theeyes until
thepatient has been assessed by a health care provider and orders are available. No other
interventions should delay flushing theeyes.
DIF:CognitiveLevel: Apply (Application)
TOP: NursingProcess: Implementation MSC:NCLEX: Physiological Integrity
32. The nurse at theeye clinic made a follow-up telephone call to a patient who underwent
cataract extraction and intraocular lens implantation theprevious day. Which information is
thepriority to communicate to thehealth care provider?
a. The patient reports that thevision has not improved.
b. The patient requests a prescription refill for next week.
c. The patient feels uncomfortable wearing an eye patch.
d. The patient reports eye pain rated 5 (on a 0 to 10 scale).
ANS: D
Postoperative cataract surgery patients usually experience little or no pain, so pain at a level 5
on a 10-point pain scale may indicate complications such as hemorrhage, infection, or
increased intraocular pressure. theother information given by thepatient indicates a need for
patient teaching or follow-up does not indicate that complications of thesurgery may be
occurring.
DIF:CognitiveLevel: Analyze (Analysis)
TOP: NursingProcess: Implementation MSC:NCLEX: Physiological Integrity
33. A patient in theemergency department reports being struck in theright eye with a fist. Which
finding is a priority for thenurse to communicate to thehealth care provider?
a. The patient reports a right-sided headache.
b. The sclera on theright eye has broken blood vessels.
c. The patient reports ―a curtain‖ over part of thevisual field.
d. The area around theright eye is bruised and tender to thetouch.
ANS: C
The patient‘s sensation that a curtain is coming across thefield of vision suggests retinal
detachment and theneed for rapid action to prevent blindness. theother findings would be
expected with thepatient‘s history of being hit in theeye.
DIF:CognitiveLevel: Analyze (Analysis)
TOP: NursingProcess: Assessment MSC:NCLEX: Physiological Integrity
34. The charge nurse observes a newly hired nurse performing all thefollowing interventions for a
patient who has just undergone right cataract removal and an intraocular lens implant. Which
action requires that thecharge nurse intervene?
a. The nurse leaves theeye shield in place.
b. The nurse encourages thepatient to cough.
c. The nurse elevates thepatient‘s head to 45 degrees.
d. The nurse applies corticosteroid drops to theright eye.
ANS: B
Because coughing will increase intraocular pressure, patients are generally taught to avoid
coughing during theacute postoperative time. theother actions are appropriate for a patient
after having this surgery.
DIF:CognitiveLevel: Apply (Application)
TOP: NursingProcess: Implementation MSC:NCLEX: Physiological Integrity
35. Which nursing activity is appropriate for theregistered nurse (RN) working in theeye clinic to
delegate to experienced assistive personnel (AP)?
a. Instilling antiviral drops for a patient with a corneal ulcer
b. Application of a warm compress to a patient‘s hordeolum
c. Instruction about hand washing for a patient with herpes keratitis
d. Checking for eye irritation in a patient with possible conjunctivitis
ANS: B
Application of cold and warm packs is included in AP education and theability to accomplish
this safely would be expected for AP working in an eye clinic. Medication administration,
patient teaching, and assessment are high-level skills appropriate for theeducation and legal
practice level of theRN.
DIF:CognitiveLevel: Apply (Application)
TOP: NursingProcess: Implementation MSC:NCLEX: Safe and Effective Care Environment
36. A patient with a head injury after a motorcycle crash arrives in theemergency department
(ED) reporting shortness of breath and severe eye pain. Which action will thenurse take first?
a. Assess cranial nerve functions.
b. Administer theprescribed analgesic.
c. Check thepatient‘s oxygen saturation.
d. Examine theeye for evidence of trauma.
ANS: C
The priority action for a patient after a head injury is to assess and maintain airway and
breathing. Because thepatient is reporting shortness of breath, it is essential that thenurse
assess theoxygen saturation. theother actions are also appropriate but are not thefirst action
thenurse will take.
DIF:CognitiveLevel: Analyze (Analysis)
TOP: NursingProcess: Implementation MSC:NCLEX: Physiological Integrity
37. Which prescribed medication would thenurse give first to a patient who has just been
admitted to a hospital with acute angle-closure glaucoma?
a. Morphine sulfate 4 mg IV
b. Mannitol (Osmitrol) 100 mg IV
c. Betaxolol (Betoptic) 1 drop in each eye
d. Acetazolamide (Diamox) 250 mg orally
ANS: B
The most immediate concern for thepatient is to lower intraocular pressure, which will occur
most rapidly with IV administration of a hyperosmolar diuretic such as mannitol. theother
medications are also appropriate for a patient with glaucoma but would not be thefirst
medication administered.
DIF:CognitiveLevel: Analyze (Analysis)
TOP: NursingProcess: Implementation MSC:NCLEX: Physiological Integrity
38. A 75-yr-old patient who lives alone at home tells thenurse, ―I am afraid of losing my
independence because my eyes don‘t work as well they used to.‖ Which action would
thenurse take first?
a. Discuss theincreased risk for falls that is associated with impaired vision.
b. Ask thepatient about what type of vision problems are being experienced.
c. Explain that there are many ways to compensate for decreases in visual acuity.
d. Suggest ways of improving thepatient‘s safety, such as using brighter lighting.
ANS: B
The nurse‘s initial action should be further assessment of thepatient‘s concerns and visual
problems. theother actions may be appropriate, depending on what thenurse finds with further
assessment.
DIF:CognitiveLevel: Analyze (Analysis)
TOP: NursingProcess: Assessment MSC:NCLEX: Safe and Effective Care Environment
39. A patient who received a corneal transplant 2 weeks ago calls theophthalmology clinic to
report that his vision has not improved with thetransplant. Which action would thenurse take?
a. Suggest thepatient arrange a ride to theclinic immediately.
b. Ask about thepresence of ―floaters‖ in thepatient‘s visual field.
c. Remind thepatient it may take months to restore vision after transplant.
d. Teach thepatient to continue using prescribed pupil-dilating medications.
ANS: C
Vision may not be restored for up to 1 year after corneal transplant. Because thepatient is not
experiencing complications of thesurgery, an emergency clinic visit is not needed. Because
―floaters‖ are not associated with complications of corneal transplant, thenurse will not need
to ask thepatient about their presence. Corticosteroid drops, not mydriatic drops, are used after
corneal transplant surgery.
DIF:CognitiveLevel: Apply (Application)
TOP: NursingProcess: Implementation MSC:NCLEX: Physiological Integrity
40. The nurse is working in an urgent care clinic that has standardized treatment protocols for
implementation by nursing staff. After reviewing thehistory, physical assessment, and vital
signs for a 60-yr-old patient as shown in theaccompanying figure, which action would
thenurse take first?