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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A productive cough is not a typical finding in early-stage Hodgkin’s lymphoma. Respiratory symptoms are more commonly associated with other conditions.
Choice B rationale
Bone and joint pain are not typical findings in early-stage Hodgkin’s lymphoma. These symptoms are more commonly associated with other conditions such as metastatic cancer or rheumatoid arthritis.
Choice C rationale
Intermittent hematuria is not a typical finding in early-stage Hodgkin’s lymphoma. Hematuria is more commonly associated with urinary tract infections or kidney conditions.
Choice D rationale
Enlarged lymph nodes are a common finding in early-stage Hodgkin’s lymphoma. This condition is characterized by the presence of Reed-Sternberg cells in the lymph nodes, leading to their enlargement.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.