Page 1970 - Saunders Comprehensive Review For NCLEX-RN

Content Area: Complex Care: Emergency Situations/Management
Health Problem: Adult Health: Eye: Inflammation/Infections/Injuries
Priority Concepts: Clinical Judgment; Tissue Integrity
Reference: Ignatavicius, Workman, Rebar (2018), p. 981.

685. Answer: 3

Rationale: If the nurse notes the presence of bright red drainage on the dressing, it
must be reported to the PHCP, because this indicates hemorrhage. Options 1, 2, and
4 are inappropriate at this time.
Test-Taking Strategy: Determine if an abnormality exists. Note the words, bright
red. Since an abnormality does exist, eliminate options that state to document and
continue to monitor because an action is needed.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Complex Care: Emergency Situations/Management
Health Problem: Adult Health: Eye: Ocular tumors, retinoblastoma
Priority Concepts: Clinical Judgment; Tissue Integrity
Reference: Lewis et al. (2017), pp. 382-383.

686. Answer: 1

Rationale: In this type of accident, the client is instructed to irrigate the eyes
immediately with running water for at least 20 minutes, or until the emergency
medical services personnel arrive. In the emergency department, the cleansing agent
of choice is usually normal saline. Calling the PHCP and going to the emergency
department delays necessary intervention. Hydrogen peroxide is never placed in the
eyes.
Test-Taking Strategy: Note the strategic word, immediate. Focus on the type of
injury and eliminate options 2 and 3 because they delay necessary intervention.
Next, eliminate option 4 because hydrogen peroxide is never placed in the eyes.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Complex Care: Emergency Situations/Management
Health Problem: Adult Health: Eye: Inflammation/Infections/Injuries
Priority Concepts: Client Education; Tissue Integrity
Reference: Lewis et al. (2017), p. 371.

687. Answer: 1, 3, 5, 6

Rationale: Following eye surgery, some scratchiness and mild eye discomfort may
occur in the operative eye and usually is relieved by mild analgesics. If the eye pain
becomes severe, the client should notify the surgeon, because this may indicate
hemorrhage, infection, or increased intraocular pressure (IOP). The nurse also would
instruct the client to notify the surgeon of increased purulent drainage, increased

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