NCLEX Review About The Aging Eye (36-40)

NCLEX Review About The Aging Eye

36. The nurse is caring for a client following enucleation. The nurse notes the presence of bright red drainage on the dressing. Which nursing action is appropriate?

a) notify the physician
b) document the finding
c) continue to monitor the drainage
d) mark the drainage on the dressing and monitor for any increase in bleeding

37. A 55-year old woman was working in her garden. She accidentally sprayed insecticide into her right eye. She calls the emergency room frantic and screaming for help. The nurse should instruct the woman to take which immediate action?

a)  call the physician
b) irrigate the eyes with water
c) come to the emergency room
d) irrigate the eyes with diluted hydrogen peroxide



38. The clinic nurse is preparing to test the visual acuity of a client using a Snellen chart. Which of the following identifies the accurate procedure for this visual acuity test?

a) the right eye is tested, followed by the left eye, and then both eyes are tested
b) both eyes are assessed together, followed by the assessment of the right and the left eyes
c) the client is asked to stand at a distance of 40 feet from the chart and asked to read the largest line in the chart
d) the client is asked to stand at a distance of 40 feet from the chart and read the line that can be read 200 feet away by an individual with unimpaired vision

39. The client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. The nurse interprets this as:

a) the client is legally blind
b) the client's vision is normal
c) the client can read at distance of 60 feet what a client with normal vision can read at 20 feet
d) the client can read only at distance of 20 feet what a client with normal vision can read at 60 feet

40. The clinic nurse notes that following several eye examinations, the physician has documented a diagnosis of legal blindness in the client's chart. The nurse reviews the results of the Snellen chart test expecting note which finding?

a) 20/20 vision
b) 20/40 vision
c) 20/60 vision
d) 20/200 vision





NCLEX Review About The Aging Eye:
ANSWERS AND RATIONALE

36) A

- If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the physician, because this indicates hemorrhage. Options B, C, and D are inappropriate.

37) B

- 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 service personnel arrive. In the emergency department, the cleansing agent of choice is normal saline. Calling the physician and going to the emergency room delays necessary intervention. Hydrogen peroxide is never placed in the eyes.

38) A

- Visual acuity is assessed in one eye at a time, and then in both eyes together, with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes are then tested together. Visual acuity is measured with or without corrective lenses and the client stands at a distance of 20 feet from the chart.

39) D

- Vision that is 20/20 is normal—that is, the client is able to read from 20 feet what a person with normal vision can read from 20 feet. A client with a visual acuity of 20/60 can only read at a distance of 20 feet what a person with normal vision can read at 60 feet.

40) D

- Legal blindness is defined as 20/200 or less with corrected vision (glasses or contact lenses) or visual acuity of less than 20 degrees of the visual field in the better eye.



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