NCLEX Review for Eyes

1. The clinic nurse is preparing to test the visual acuity of a client using a Snellen’s chart. Which of the following identifies the accurate procedure for this visual acuity test?

a. Both eyes are assessed together, followed by the assessment of the right and then the left eye.
b. The right eye is tested followed by the left eye, and then both eyes are tested.
c. The client is asked to stand at a distance of 40ft. from the chart and is asked to read the largest line on the chart.
d. The client is asked to stand at a distance of 40ft from the chart and to read the line than can be read 200 ft away by an individual with unimpaired vision.

2. The clinic nurse notes that the following several eye examinations, the physician has documented a diagnosis of legal blindness in the client’s chart. The nurse reviews the results of the Snellen’s chart test expecting to note which of the following?

a. 20/20 vision
b. 20/40 vision
c. 20/60 vision
d. 20/200 vision

3. The client’s vision is tested with a Snellen’s chart. The results of the tests are documented as 20/60. The nurse interprets this as:

a. The client can read at a distance of 60 feet what a client with normal vision can read at 20 feet.
b. The client is legally blind.
c. The client’s vision is normal
d. The client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet.

4. Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse analyzes the test results as documented in the client’s chart and understands that normal intraocular pressure is:

a. 2-7 mmHg
b. 10-21 mmHg
c. 22-30 mmHg
d. 31-35 mmHg

5. The nurse is developing a plan of care for the client scheduled for cataract surgery. The nurse documents which more appropriate nursing diagnosis in the plan of care?

a. Self-care deficit
b. Imbalanced nutrition
c. Disturbed sensory perception
d. Anxiety

6. The nurse is performing an assessment in a client with a suspected diagnosis of cataract. The chief clinical manifestation that the nurse would expect to note in the early stages of cataract formation is:

a. Eye pain
b. Floating spots
c. Blurred vision
d. Diplopia

7. In preparation for cataract surgery, the nurse is to administer prescribed eye drops. The nurse reviews the physicians orders, expecting which type of eye drops to be instilled?

a. An osmotic diuretic
b. A miotic agent
c. A mydriatic medication
d. A thiazide diuretic

8. During the early postoperative period, the client who had a cataract extraction complains of nausea and severe eye pain over the operative site. The initial nursing action is to:

a. Call the physician
b. Administer the ordered main medication and antiemetic
c. Reassure the client that this is normal.
d. Turn the client on his or her operative side

9. The client is being discharged from the ambulatory care unit following cataract removal. The nurse provides instructions regarding home care. Which of the following, if stated by the client, indicates an understanding of the instructions?

a. “I will take Aspirin if I have any discomfort.”
b. “I will sleep on the side that I was operated on.”
c. “I will wear my eye shield at night and my glasses during the day.”
d. “I will not lift anything if it weighs more that 10 pounds.”

10. The client with glaucoma asks the nurse is complete vision will return. The most appropriate response is:

a. “Although some vision as been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan.”
b. “Your vision will return as soon as the medications begin to work.”
c. “Your vision will never return to normal.”
d. “Your vision loss is temporary and will return in about 3-4 weeks.”

11. 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?

a. Decrease fluid intake to control the intraocular pressure
b. Avoid overuse of the eyes
c. Decrease the amount of salt in the diet
d. Eye medications will need to be administered lifelong.

12. 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?

a. Pain in the affected eye
b. Total loss of vision
c. A sense of a curtain falling across the field of vision
d. A yellow discoloration of the sclera.

13. 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?

a. Complaints of a burst of black spots or floaters
b. A sudden sharp pain in the eye
c. Total loss of vision
d. A reddened conjunctiva

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

a. Notify the physician
b. Irrigate the eye with cold water
c. Apply ice to the affected eye
d. Accompany the client to the emergency room

15. 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?

a. Remove the piece of wood using a sterile eye clamp
b. Apply an eye patch
c. Perform visual acuity tests
d. Irrigate the eye with sterile saline.

16. 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:

a. Begin visual acuity testing
b. Irrigate the eye with sterile normal saline
c. Swab the eye with antibiotic ointment
d. Cover the eye with a pressure patch.

17. 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?

a. Notify the physician
b. Continue to monitor the drainage
c. Document the finding
d. Mark the drainage on the dressing and monitor for any increase in bleeding.

18. 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?

a. The client has alterations in near vision and is legally blind.
b. The client can see at 20 feet what the person with normal vision can see at 40 feet.
c. The client can see at 40 feet what the person with normal vision sees at 20 feet.
d. The client has a 20% decrease in acuity in one eye, and a 40% decrease in the other eye.

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

a. Goniometer
b. Ophthalmoscope
c. Slit lamp
d. Tonometer

20. 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?

a. “Be careful because the blink reflex is paralyzed.”
b. “Avoid wearing your regular glasses when driving.”
c. “Be aware that the pupils may be unusually small.”
d. “Wear dark glasses in bright light because the pupils are dilated.”

(ANSWERS and RATIONALE) – NCLEX Review for Eyes

Latest Comments
  1. sobz

    answers?

  2. ferwinadansalan

    1b 2c 3b 4c 5c 6d 7a 8b 9c 10b 11a 12a 13a 14c 15c 16b 17a 18d 19d 20d

  3. Hemraj Jat

    nice

  4. jernalyn leprozo

    where can I get the answers?

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