ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 47 Questions
Question 1 of 5
A client is brought to the emergency department after a car crash. The client has a large piece of glass in the left eye. What action by the nurse takes priority?
Correct Answer: B
Rationale: Airway always comes first in emergency care. After ensuring a patent airway and providing cervical spine precautions, other care such as administering a tetanus booster shot may be considered. The eye should not be irrigated with a foreign body present.
Question 2 of 5
A client has a foreign body in the eye. What action by the nurse takes priority?
Correct Answer: A
Rationale:
To prevent infection, antibiotics are provided. Visual acuity in the affected eye cannot be assessed with a foreign body present. Enucleation is not typically required, and only an ophthalmologist should remove the foreign body.
Question 3 of 5
A client is taking timolol (Timoptic) eyedrops. The nurse assesses the clients pulse at 50 beats/min. What action by the nurse is best?
Correct Answer: D
Rationale: Timolol is a beta blocker that can slow the heart rate. A pulse of 50 beats/min warrants holding the eyedrops and notifying the provider. Excessive salivation and shortness of breath are not typically related to timolol.
Question 4 of 5
A client is seen in the ophthalmology clinic with bacterial conjunctivitis. Which statements by the client indicate correct understanding? (Select all that apply.)
Correct Answer: C,D
Rationale: Bacterial conjunctivitis is very contagious, and re-infection or cross-contamination must be avoided. Not touching the eyedrop bottle tip to the eye and using prescribed antibiotics are correct actions. Sharing towels, improper irrigation, or premature contact lens use can worsen or spread the infection.
Question 5 of 5
The nurse working in the ophthalmology clinic sees clients with eyelid and eye problems. What information should the nurse understand about these disorders? (Select all that apply.)
Correct Answer: A,D,E
Rationale: A chalazion is an inflammation of one of the sebaceous glands in the eyelid. A hordeolum is an infection of a sweat gland in the eyelid. Keratoconjunctivitis sicca can be caused by drugs or diseases. An ectropion is an outward turning and sagging eyelid, while an entropion is an inward turning of the eyelid.