Eye Correction (NCLEX 71-75)

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71. A nurse receives a telephone call from a neighbor, who tells the nurse that the spouse accidentally broke a mirror, and a piece of glass flew into the eye. The nurse arrives at the home and finds that a piece of glass is protruding from the victim's eye. The nurse should:

a) remove the piece of glass using a tweezers that was boiled for sterilization purposes
b) apply an eye patch and instruct the victim and spouse to report to the emergency department
c) accompany the victim and spouse to the emergency department
d) flush the eye thoroughly with tap water


72. A client arrives at the emergency department after an eye injury in which an acid used to clean the bricks on a fireplace splashed into his eye. The initial assessment question by the nurse is which of the following?

a) did you bring the container of acid with you?
b) what time did the injury occur?
c) did you flush the eye following the injury?
d) what type of acid caused the injury?

73. A nurse is caring for a client following enucleation. Which of the following assessment findings would indicate the need to notify the physician?

a) bright red drainage on the dressing
b) a respiratory rate of 22 breaths per minute
c) complaints of pain in the affected eye
d) a blood pressure of 138/88 mm Hg

74. A client is being discharged from the ambulatory care unit after cataract removal, and the nurse provides instructions regarding home care. Which of the following should the nurse tell the client?

a) take acetaminophen (Tylenol) if any discomfort occurs
b) sleep on the side that was operated on to promote drainage
c) avoid wearing glasses
d) do not lift anything that weighs more than 20 pounds

75. An ambulatory care nurse provides instructions to a client after a cataract extraction. Which statement by the client indicates a need for further instructions?

a) I need to avoid bending over to pick up items
b) I will sleep on the unoperative side
c) I need to wear an eye shield all the time
d) There is no reason to stay on a special diet






Eye Correction
Answers and Rationale

71) C

- If an eye injury is the result of a penetrating object, the object may be noted protruding from the eye. This object must never be removed except by the ophthalmologist because it may be holding ocular structures in place. Application of an eye patch or irrigation of the eye may disrupt the foreign body and cause further tearing of the cornea. The most appropriate action by the nurse from the options presented is to accompany the victim to the emergency department.

72) C

- Emergency care following a chemical burn of the eye includes irrigating the eye immediately with tap water or sterile normal saline or ocular irrigating solution if available. The irrigation should be maintained for at least 10 minutes. Following this emergency treatment, visual acuity is assessed. The initial assessment in this situation should focus on the type of treatment that took place immediately following the injury.

73) A

- If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the physician because this can indicate hemorrhage. Complaints of pain are expected in the postoperative period. A blood pressure of 138/88 mm Hg is within normal range. A respiratory rate of 22 breaths per minute, although slightly elevated from the normal range, does not warrant physician notification.

74) A

- The client is instructed to wear a metal or plastic shield to protect the eye from accidental injury and is instructed not to rub the eye. Glasses may be worn during the day, and an eye shield is worn at night. Aspirin or medications containing aspirin are not to be administered or taken by the client; the client is instructed to take acetaminophen (Tylenol) as needed for pain. The client is instructed not to sleep on the side of the body that was operated on because this action will cause edema and increased intraocular pressure. The client is not to lift more than 5 pounds.

75) C

- Postoperatively, cataract extraction clients should be positioned on their backs in semi-Fowler position or on the unoperative side to prevent edema in the surgical site. They need to avoid bending at the waist and other activities that will increase intraocular pressure. A special diet is not necessary following this procedure. The client needs to wear an eye shield at night to prevent injury to the eye during sleep. Eyeglasses or an eye patch may be worn during the day.


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Eye Correction NCLEX Questions (1-6)