NCLEX Quiz: Eye Disorders And Care

1. The client arrives in the emergency room after sustaining a chemical eye injury from a splash of battery acid. The initial nursing action is to:

Begin visual acuity testing

Irrigate the eye with sterile normal saline

Swab the eye with antibiotic ointment

Cover the eye with a pressure patch.

Emergency care following a chemical burn to the eye includes irrigating the eye immediately with sterile normal saline or ocular irrigating solution. In the emergency department. the irrigation should be maintained for at least 10 minutes. Following this emergency treatment. visual acuity is assessed.

Explanation

Emergency care following a chemical burn to the eye includes irrigating the eye immediately with sterile normal saline or ocular irrigating solution. In the emergency department. the irrigation should be maintained for at least 10 minutes. Following this emergency treatment. visual acuity is assessed.

2. The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which of the following is associated with this eye disorder?

Pain in the affected eye

Total loss of vision

A sense of a curtain falling across the field of vision

A yellow discoloration of the sclera.

A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options B and D are not characteristics of this disorder. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal.

Explanation

A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options B and D are not characteristics of this disorder. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal.

3. Which of the following instruments is used to record intraocular pressure?

Goniometer

Ophthalmoscope

Slit lamp

Tonometer

A tonometer is a device used in glaucoma screening to record intraocular pressure. A goniometer measures joint movement and angles. An ophthalmoscope examines the interior of the eye. especially the retina. A slit lamp evaluates structures in the anterior chamber in the eye.

Explanation

A tonometer is a device used in glaucoma screening to record intraocular pressure. A goniometer measures joint movement and angles. An ophthalmoscope examines the interior of the eye. especially the retina. A slit lamp evaluates structures in the anterior chamber in the eye.

4. After the nurse instills atropine drops into both eyes for a client undergoing ophthalmic examination. which of the following instructions would be given to the client?

“Be careful because the blink reflex is paralyzed.”

“Avoid wearing your regular glasses when driving.”

“Be aware that the pupils may be unusually small.”

“Wear dark glasses in bright light because the pupils are dilated.”

Atropine. an anticholinergic drug. has mydriatic effects causing pupil dilation. This allows more light onto the retina and may cause photophobia and blurred vision. Atropine doesn’t paralyze the blink reflex or cause miosis (pupil constriction). Driving may be contraindicated to blurred vision.

Explanation

Atropine. an anticholinergic drug. has mydriatic effects causing pupil dilation. This allows more light onto the retina and may cause photophobia and blurred vision. Atropine doesn’t paralyze the blink reflex or cause miosis (pupil constriction). Driving may be contraindicated to blurred vision.

5. The nurse is caring for a client with a diagnosis of detached retina. Which assessment sign would indicate that bleeding has occurred as a result of the retinal detachment?

Complaints of a burst of black spots or floaters

A sudden sharp pain in the eye

Total loss of vision

A reddened conjunctiva

Complaints of a sudden burst of black spots or floaters indicate that bleeding has occurred as a result of the detachment.

Explanation

Complaints of a sudden burst of black spots or floaters indicate that bleeding has occurred as a result of the detachment.

6. When using a Snellen alphabet chart. the nurse records the client's vision as 20/40. Which of the following statements best describes 20/40 vision?

The client has alterations in near vision and is legally blind.

The client can see at 20 feet what the person with normal vision can see at 40 feet.

The client can see at 40 feet what the person with normal vision sees at 20 feet.

The client has a 20% decrease in acuity in one eye. and a 40% decrease in the other eye.

The numerator refers to the client’s vision while comparing the normal vision in the denominator.

Explanation

The numerator refers to the client’s vision while comparing the normal vision in the denominator.

7. The nurse is developing a teaching plan for the client with glaucoma. Which of the following instructions would the nurse include in the plan of care?

Decrease fluid intake to control the intraocular pressure

Avoid overuse of the eyes

Decrease the amount of salt in the diet

Eye medications will need to be administered lifelong.

The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his or her life.

Explanation

The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his or her life.

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

Notify the physician

Continue to monitor the drainage

Document the finding

Mark the drainage on the dressing and monitor for any increase in bleeding.

If the nurse notes the presence of bright red drainage on the dressing. it must be reported to the physician because this indicated hemorrhage.

Explanation

If the nurse notes the presence of bright red drainage on the dressing. it must be reported to the physician because this indicated hemorrhage.

9. The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention is initiated immediately?

Notify the physician

Irrigate the eye with cold water

Apply ice to the affected eye

Accompany the client to the emergency room

Treatment for contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by a physician and receive a thorough eye examination to rule out the presence of other eye injuries.

Explanation

Treatment for contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by a physician and receive a thorough eye examination to rule out the presence of other eye injuries.

10. The client arrives in the emergency room with a penetrating eye injury from wood chips while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. what is the initial nursing action?

Remove the piece of wood using a sterile eye clamp

Apply an eye patch

Perform visual acuity tests

Irrigate the eye with sterile saline.

If the laceration is the result of a penetrating injury. an 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 sclera. (The only option that will prevent further disruption is to assess visual acuity.)

Explanation

If the laceration is the result of a penetrating injury. an 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 sclera. (The only option that will prevent further disruption is to assess visual acuity.)

NCLEX Quiz: Eye Disorders And care