The nurse is collecting data from a patient with a detached retina. Which findings should the nurse expect in this patient? (Select all that apply.)
a. Severe pain
b. Blurred vision
c. Flashing lights
d. Loss of peripheral vision
e. Loss of acuity in the affected eye
ANS: E
Patients experiencing a retinal detachment report a sudden change in vision. Initially, as the retina is pulled, patients report seeing flashing lights and then floaters. The flashing lights are caused by vitreous traction on the retina, and the floaters are caused by hemorrhage of vitreous fluid or blood. On visual examination, the patient typically has a loss of peripheral vision when the visual fields are tested and a loss of acuity in the affected eye. A. There is no pain because the retina does not contain sensory nerves. B. Blurred vision does not occur with a detached retina.
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Standard Text: Select all that apply. 1. Open the capsule and pour the contents into 5 mL of water, and mix it well. 2. Crush all of the client's tablets to a fine powder, and mix in applesauce. 3. Flush the n/g tube with water after each medication. 4. Check tube placement before beginning to administer medications. 5. Flush n/g tube with water after last medication is administered.
A client is being seen in the clinic to receive the results of the lab work to determine thyroid levels. The nurse observes the client's eyes appear to be bulging, and there is swelling around the eyes
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The nurse would initiate which method to facilitate drying of the antiseptic solution applied to the intravenous site?
1. Fan the area 2. Blot the area 3. Blow on the area 4. Allow the area to dry itself
A nurse who is caring for a client receiving total parentral nutrition (TPN) must be careful to:
1. Follow the facility protocol for tapering TPN and monitor the input and output for the client each shift. 2. Decrease the amount of TPN slowly based on the oral intake of the patient. 3. Follow the facility protocol for tapering TPN, especially monitoring blood sugar levels. 4. Stop TPN in the morning and resume oral feeding beginning with clear liquids.