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'm afraid of falling."
"My eye really itches, but I'm trying not to rub it."
"The bright light in this room is really bothering me."
"I need something for the pain in my eye. I can't stand it."
The Correct Answer is D
Choice A reason: This is incorrect because this comment does not require reporting to the client's provider. It is normal to have reduced vision and an increased risk of falling with a patch on one eye after cataract surgery. The nurse should reassure the client, provide assistance with mobility, and educate the client on safety measures.
Choice B reason: This is incorrect because this comment does not require reporting to the client's provider. It is normal to have some itching and discomfort in the eye after cataract surgery. The nurse should commend the client for not rubbing the eye, as this can cause infection or damage to the surgical site. The nurse should also administer anti-inflammatory eye drops as prescribed and instruct the client on how to apply them.
Choice C reason: This is incorrect because this comment does not require reporting to the client's provider. It is normal to have increased sensitivity to light in the eye after cataract surgery. The nurse should dim the lights in the room, provide sunglasses or a shield for the eye, and educate the client on how to protect the eye from bright light.
Choice D reason: This is the correct answer because this comment requires reporting to the client's provider. Severe pain in the eye after cataract surgery can indicate a complication such as infection, inflammation, bleeding, or increased intraocular pressure. The nurse should assess the eye for signs of redness, swelling, discharge, or bleeding, and report the findings and the pain level to the provider. The nurse should also administer analgesics as prescribed and monitor the pain relief.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is incorrect because education about mastoidectomy is not relevant for a client with an upper respiratory infection. Mastoidectomy is a surgical procedure that removes part or all of the mastoid bone behind the ear, which can become infected or inflamed due to chronic or recurrent middle ear infections. The nurse should assess
the client's ear for signs of mastoiditis, such as swelling, tenderness, or redness behind the ear, but mastoidectomy is not a common or first-line treatment for upper respiratory infection.
Choice B reason: This is incorrect because a referral for a hearing test is not necessary for a client with an upper respiratory infection. Hearing test is a diagnostic tool that measures how well a person can hear different sounds at different frequencies and intensities. The nurse should ask the client about any changes in hearing or tinnitus, which are possible complications of upper respiratory infection, but a hearing test is not a routine or urgent intervention for this condition.
Choice C reason: This is correct because education on the administration of oral antibiotics can help treat an upper respiratory infection. Antibiotics are drugs that kill or inhibit bacteria that cause infections. Upper respiratory infections can be caused by various pathogens, such as viruses, bacteria, or fungi, but bacterial infections are more likely to cause fever, otalgia, or purulent nasal drainage. The nurse should instruct the client on how to take antibiotics as prescribed, such as dosage, frequency, duration, side effects, and interactions.
Choice D reason: This is incorrect because a prescription for an antifungal cream is not appropriate for a client with an upper respiratory infection. Antifungal cream is a topical medication that kills or inhibits fungi that cause skin infections. Upper respiratory infection is not a skin infection, but an infection of the nose, throat, or sinuses. Antifungal cream has no effect on upper respiratory infection and may cause adverse effects or resistance.

Correct Answer is C
Explanation
Choice A reason: This is incorrect because using sign language when communicating with the client is not an appropriate action for the nurse to take. Sign language is a form of communication that uses hand gestures, facial expressions, and body movements. It is not a universal language and requires training and practice. The nurse should not assume that the client knows or prefers sign language unless they have indicated so.
Choice B reason: This is incorrect because speaking loudly and into the client's good ear is not an appropriate action for the nurse to take. Speaking loudly can distort the sound quality and cause discomfort or irritation to the client. Speaking into the client's good ear can also create a sense of imbalance and isolation. The nurse should speak at a normal volume and tone, and face the client directly.
Choice C reason: This is the correct answer because speaking directly to the client in a normal, clear voice is an appropriate action for the nurse to take. Speaking directly to the client can help them see the nurse's mouth movements and facial expressions, which can enhance understanding and communication. Speaking in a normal, clear voice can help convey the message clearly and respectfully.
Choice D reason: This is incorrect because sitting by the client's side and speaking very slowly is not an appropriate action for the nurse to take. Sitting by the client's side can make it difficult for them to see the nurse's face and hear their voice. Speaking very slowly can also make the message unclear and patronizing. The nurse should sit in front of the client and speak at a normal pace.

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