Chapter 19: Care of the Eye and Ear

Chapter 19: Care of the Eye and Ear

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. The nurse decides that assistive personnel can provide care to a patient with contact lenses when the assistive personnel states:

a.	“If I am in a hurry, I will use tap water for rinsing the lenses.”
b.	“Gloves aren’t necessary; the eye is a clean organ.”
c.	“I will check with the patient to see if the lenses are disposable.”
d.	“It is normal for contact lens wearers to have red, teary eyes.”

 

 

ANS:  C

Let the patient be a resource in the care of each device. Although it is the nurse’s responsibility to ensure that patients do not damage their devices or injure themselves, patients familiar with their devices are likely to have an established routine and helpful tips. The replacement schedule is determined by the type of lenses the patient wears; the patient can provide that information. Tap water can contain microorganisms and may be absorbed into the lens, making it uncomfortable to wear. Clean, powder-free gloves are used to prevent the spread of microorganisms during care of contact lenses. Pain, tearing, discomfort, and redness can indicate conjunctivitis and should be referred to the patient’s provider if symptoms persist.

 

DIF:    Cognitive Level: Comprehension     REF:   Text reference: pp. 456-457

OBJ:   Identify guidelines used in caring for eye and ear prostheses.

TOP:   Contact Lenses                                KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

2. When providing eye care for the comatose patient, the nurse should:

a.	place the patient in a prone position for easier access.
b.	use a different corner of the washcloth for each eye.
c.	wipe each eye from outer to inner canthus.
d.	use a sterile medicine cup to instill lubricant.

 

 

ANS:  B

Use a separate, clean cotton ball or corner of the washcloth for each eye. Place the patient in supine position. Gently wipe each eye from inner to outer canthus. Use an eyedropper to instill the prescribed lubricant (e.g., saline, methylcellulose, liquid tears) as ordered.

 

DIF:    Cognitive Level: Application           REF:   Text reference: p. 455

OBJ:   Identify guidelines used in caring for eye and ear prostheses.

TOP:   Eye Care for a Comatose Patient      KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

3. In caring for a patient with contact lenses, the nurse should be aware that:

a.	rigid gas-permeable (RGP) lenses are no longer used.
b.	soft contact lenses are smaller than the cornea.
c.	all lenses must be removed periodically.
d.	extended wear lenses can be used for only 6 nights.

 

 

ANS:  C

It is important to remember that all lenses must be removed periodically to prevent infection and corneal damage, and that proper cleaning is necessary before a lens is reinserted. Two basic types of contact lenses are used today: RGP and soft. Rigid contact lenses are made of firm, durable plastic and are smaller than the cornea. Soft contact lenses are made of a flexible hydrogel plastic and cover the entire cornea and a small rim of the sclera. Although the limit for extended wear lenses is usually 6 nights, certain soft lenses have been approved for continuous wear up to 30 nights.

 

DIF:    Cognitive Level: Application           REF:   Text reference: p. 455

OBJ:   Identify guidelines used in caring for eye and ear prostheses.

TOP:   Contact Lenses                                KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

4. Which of the following nursing interventions would the nurse perform first after a patient sustained a chemical splash injury to the eye?

a.	Assess visual acuity.
b.	Flush the eye with large amounts of irrigation fluid.
c.	Assess level of pain.
d.	Determine whether the pupils are PERRLA.

 

 

ANS:  B

The first thing the nurse should do when caring for a patient who has sustained a chemical injury to the eye is flush the eye with large amounts of irrigation fluid. Assessing visual acuity, pain, and PERRLA will be performed after the eye has been irrigated appropriately.

 

DIF:    Cognitive Level: Application           REF:   Text reference: p. 460

OBJ:   Identify nursing care for a patient with a chemical splash to the eye.

TOP:   Splash to Eye                                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

5. The nurse caring for a comatose patient determines that he is wearing contact lenses. Which of the following nursing interventions will the nurse use when removing the contact lenses?

a.	Put on snug, powdered, clean gloves.
b.	Ask the patient to look down to expose the lower eyeball.
c.	Use the fingernail to slide the lens off of the cornea.
d.	Inspect the eye after the lenses have been removed.

 

 

ANS:  D

After the lenses have been removed, inspect the eye for redness, pain, swelling of the eyelids or conjunctivae, discharge, or excess tearing. Perform hand hygiene. Don snug, powder-free, clean gloves, and place a towel just below the patient’s face. Ask the patient to look up to expose the lower eyeball to which the lens will be displaced. With the pad of the index finger of the same hand, slide the lens off the cornea down onto the lower sclera. Use of the pad rather than the fingernail prevents injury to the cornea and damage to the lens.

 

DIF:    Cognitive Level: Application           REF:   Text reference: p. 456

OBJ:   Correctly remove, store, clean, and insert a contact lens.     TOP:   Removal of Contact Lenses

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity