A nurse is caring for a client who is postoperative following a left corneal transplant.

The nurse observes purulent drainage from the affected eye.

Which of the following actions is the nurse’s priority?

Apply a non-pressure patch to the affected eye.

Clean the eye from inner to outer canthus.

Notify the surgeon.

Instill an antibiotic solution in both eyes.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Applying a non-pressure patch to the affected eye can help protect the eye from further irritation or injury. However, it does not address the underlying issue of purulent drainage, which could indicate an infection that requires immediate medical attention.

Choice B rationale

Cleaning the eye from inner to outer canthus is a standard practice to prevent the spread of infection. However, in this case, the presence of purulent drainage suggests a possible infection that needs to be evaluated by a surgeon.

Choice C rationale

Notifying the surgeon is the priority action because purulent drainage from the eye can indicate a serious infection or complication following surgery. Immediate medical evaluation and intervention are necessary to prevent further complications and ensure proper treatment.

Choice D rationale

Instilling an antibiotic solution in both eyes may be part of the treatment plan for an infection. However, the nurse should first notify the surgeon to get appropriate orders and ensure that the correct antibiotic and treatment plan are followed.

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Correct Answer is C

Explanation

Choice A rationale

Auscultating for wheezing is important but not the first action. The priority is to administer epinephrine to counteract the severe allergic reaction.

Choice B rationale

Assessing the client’s level of consciousness is important but not the first action. Administering epinephrine takes precedence to stabilize the client’s condition.

Choice C rationale

Administering epinephrine is the first action. It is crucial to counteract the severe allergic reaction and prevent further complications.

Choice D rationale

Monitoring for hypotension is important but not the first action. Administering epinephrine is the priority to stabilize the client’s condition.

A. Expect reduced vision for 48 hours after the procedure. B. Restrict lifting objects greater than 10 pounds. C. Take aspirin for discomfort. D. Apply warm compresses for discomfort.

Correct Answer is B

Explanation

Choice A rationale

Vision may be temporarily blurred after intraocular lens surgery, but significant vision reduction for 48 hours is not typical and should be reported to a healthcare provider.

Choice B rationale

Restricting lifting objects greater than 10 pounds is crucial to prevent increased intraocular pressure and potential complications after surgery.

Choice C rationale

Aspirin should be avoided as it can increase the risk of bleeding. Alternative pain relief methods should be used.

Choice D rationale

Warm compresses are not recommended as they can increase inflammation and discomfort. Cold compresses may be more appropriate.

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A nurse is caring for a client who is postoperative following a left corneal transplant. The nurse observes purulent drainage from the affected eye. Which of the following actions is the nurse’s priority?

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A nurse is caring for a client who is postoperative following a left corneal transplant.

The nurse observes purulent drainage from the affected eye.

Which of the following actions is the nurse’s priority?