Question

A nurse is caring for a client who is postoperative following a left corneal transplant. he nurse observes purulent drainage from the affected eye. Which of the following actions is the nurse’s priority?

Answer 1

Correct Answers:

Notify the surgeon.

Rationale :

🔷 Purulent drainage from a surgical site suggests infection, which is a serious complication after a corneal transplant.

🔷 The priority is to report this to the surgeon immediately to prevent further complications like endophthalmitis, which can lead to vision loss.

🔷 Interventions such as antibiotic instillation or eye patching should only occur after provider notification and direction.

🔷 This situation reflects the “report significant findings” guideline in post-op care.

🔷 Using SBAR communication ensures effective, timely collaboration with the surgeon.

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Answer 2

Correct Answers:

“I need something for the pain in my eye. I can’t stand it.”.

Rationale :

💠 Severe eye pain following cataract surgery is abnormal and may indicate complications such as increased intraocular pressure or hemorrhage.

💠 While itching or light sensitivity may occur, intense pain warrants immediate provider notification.

💠 Clients typically describe only mild discomfort postoperatively.

💠 Prompt evaluation can prevent permanent vision loss.

💠 Pain management alone is not appropriate without first identifying the underlying cause.

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Answer 3

Correct Answers:

Apply the ointment in a thin line into the conjunctival sac.

Rationale :

🔸 The proper method of applying ophthalmic ointment is to pull the lower lid down and apply a thin line into the conjunctival sac, from inner to outer canthus.

🔸 This ensures direct contact with the infected tissue and helps avoid injury to the cornea.

🔸 The child should be instructed to look up, not down, during application.

🔸 Sterile gloves may be used, but clean technique is usually sufficient in non-surgical situations.

🔸 Teaching technique prevents cross-contamination and improves medication efficacy.

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Answer 4

Correct Answers:

Restrict head movement.

Rationale :

⚫ After retinal detachment, limiting head and eye movement reduces the risk of further retinal separation and promotes healing.

⚫ Eye patches and mydriatic (not miotic) drops are often used postoperatively, not preoperatively.

⚫ Restricting activity supports the formation of the retinopexy seal during surgical healing.

⚫ Client safety and surgical success depend on adherence to immobility protocols.

⚫ Sudden movements may displace gas or oil tamponades used in the procedure.

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Answer 5

Correct Answers:

Shut off the intravenous infusion.

Rationale :

🟢 Difficulty swallowing during infliximab infusion is a sign of hypersensitivity or anaphylaxis.

🟢 The immediate action is to stop the infusion to prevent worsening of the reaction.

🟢 This is consistent with the “stop the source” first rule for IV adverse reactions.

🟢 Airway assessment and emergency support follow after stopping the causative agent.

🟢 Continuing the infusion could cause respiratory compromise or cardiac arrest.

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Answer 6

Correct Answers:

Having a decreased ability to perceive colors.

Rationale :

🔴 Cataracts cause lens clouding, leading to blurry vision and color discrimination problems.

🔴 Clients often describe difficulty recognizing blues and purples, or complain about faded vision.

🔴 Loss of peripheral vision and floaters are more related to glaucoma or retinal issues.

🔴 Cataracts typically cause gradual visual decline, including glare sensitivity.

🔴 Assessing color changes supports diagnosis and surgical planning.

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Answer 7

Correct Answers:

Intubation equipment and oxygen.
Epinephrine.

Rationale :

🟠 Intubation and oxygen are required in cases of airway compromise due to anaphylaxis.

🟠 Preparation ensures rapid airway support in case of angioedema or respiratory arrest.

🟠 Early readiness is vital during severe allergic reaction cases.

🟠 Epinephrine is the first-line treatment for anaphylaxis and reverses bronchoconstriction and vasodilation.

🟠 Administered IM in the vastus lateralis, epinephrine restores perfusion and breathing.

🟠 Timely administration saves lives and prevents full shock progression.

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Answer 8

Correct Answers:

CD4-T-cell count 180 cells/mm³.

Rationale :

🟣 A CD4 count <200 indicates severe immunosuppression and defines AIDS.

🟣 Clients are at high risk for opportunistic infections like Pneumocystis pneumonia or toxoplasmosis.

🟣 The priority is to assess for early signs of infection and initiate prophylactic treatment.

🟣 This value guides medication adjustments (e.g., HAART regimen).

🟣 Close monitoring is crucial for preventing life-threatening complications.

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Answer 9

Correct Answers:

FLACC.

Rationale :

🟡 The FLACC scale is the preferred tool for assessing pain in infants and nonverbal children.

🟡 It evaluates Facial expression, Leg movement, Activity, Crying, and Consolability.

🟡 Appropriate for a 6-month-old who is unable to verbalize pain.

🟡 The scale allows for objective and consistent pain assessment.

🟡 Early recognition of pain supports timely pain management post-surgery.

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Answer 10

Correct Answers:

Basal cell carcinoma.

Rationale :

🔷 Basal cell carcinoma is characterized by pearly, waxy borders and a raised, flesh-colored lesion.

🔷 It is the most common type of skin cancer and grows slowly, rarely metastasizing.

🔷 The central ulceration or telangiectasia (fine red vessels) may also be present.

🔷 Often occurs in sun-exposed areas, particularly in fair-skinned individuals.

🔷 Early recognition improves outcomes with surgical excision or cryotherapy.

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RN Capstone week 10 Exam

No.

1 :
A nurse is caring for a client who is postoperative following a left corneal transplant. he nurse observes purulent drainage from the affected eye. Which of the following actions is the nurse’s priority?

2 :
A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client’s provider?

3 :
A nurse is instructing the caregiver of a child who has bacterial conjunctivitis and a new prescription for an ophthalmic ointment. Which of the following instructions should the nurse provide?

4 :
A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following instructions should the nurse include?

5 :
A client receiving infliximab through intravenous infusion is reporting difficulty swallowing. Which immediate action would the nurse take?

6 :
A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report:

7 :
While working in the emergency department, the unit secretary says, “We just got a call that someone with a severe peanut allergy accidentally ate peanuts and is on the way.”. Which emergency equipment would the nurse gather to prepare for the client’s arrival? Select all that apply.

8 :
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse’s priority?

9 :
A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant’s pain level?

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RN Capstone week 10 Exam

No.

1 : A nurse is caring for a client who is postoperative following a left corneal transplant. he nurse observes purulent drainage from the affected eye. Which of the following actions is the nurse’s priority?

2 : A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client’s provider?

3 : A nurse is instructing the caregiver of a child who has bacterial conjunctivitis and a new prescription for an ophthalmic ointment. Which of the following instructions should the nurse provide?

4 : A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following instructions should the nurse include?

5 : A client receiving infliximab through intravenous infusion is reporting difficulty swallowing. Which immediate action would the nurse take?

6 : A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report:

7 : While working in the emergency department, the unit secretary says, “We just got a call that someone with a severe peanut allergy accidentally ate peanuts and is on the way.”. Which emergency equipment would the nurse gather to prepare for the client’s arrival? Select all that apply.

8 : A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse’s priority?

9 : A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant’s pain level?

1 :
A nurse is caring for a client who is postoperative following a left corneal transplant. he nurse observes purulent drainage from the affected eye. Which of the following actions is the nurse’s priority?

2 :
A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client’s provider?

3 :
A nurse is instructing the caregiver of a child who has bacterial conjunctivitis and a new prescription for an ophthalmic ointment. Which of the following instructions should the nurse provide?

4 :
A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following instructions should the nurse include?

5 :
A client receiving infliximab through intravenous infusion is reporting difficulty swallowing. Which immediate action would the nurse take?

6 :
A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report:

7 :
While working in the emergency department, the unit secretary says, “We just got a call that someone with a severe peanut allergy accidentally ate peanuts and is on the way.”. Which emergency equipment would the nurse gather to prepare for the client’s arrival? Select all that apply.

8 :
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse’s priority?

9 :
A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant’s pain level?