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1. Question
The nurse is caring for a client following enucleation. The nurse notes the presence of bright red drainage on the dressing. Which nursing action is appropriate?
Correct
Answer & Rationale:
Option 1 is Correct
Rationale: If the nurse notes the presence of bright red drainage on the dressing, itmust be reported to the physician, because this indicates hemorrhage. Options 2, 3, and 4 are inappropriate.
Test-Taking Strategy: Use the process of elimination and note the strategic words bright red. Remember that bright red drainage indicates active bleeding. Review postoperative complications associated with an enucleation if you had difficultywith this question.
Incorrect
Answer & Rationale:
Option 1 is Correct
Rationale: If the nurse notes the presence of bright red drainage on the dressing, itmust be reported to the physician, because this indicates hemorrhage. Options 2, 3, and 4 are inappropriate.
Test-Taking Strategy: Use the process of elimination and note the strategic words bright red. Remember that bright red drainage indicates active bleeding. Review postoperative complications associated with an enucleation if you had difficultywith this question.
Enucleation and exenteration
Description
Enucleation is the removal of the entire eyeball.
Exenteration is the removal of the eyeball and surrounding tissues and bone.
The procedures are performed for the removal of ocular tumors.
After the eye is removed, a ball implant is inserted to provide a firm base for a socket prosthesis and to facilitate the best cosmetic result.
A prosthesis is fitted about 1 month after surgery.
Preoperative interventions
Provide emotional support to the client.
Encourage the client to verbalize feelings related to loss.
Postoperative interventions
Monitor vital signs.
Assess a pressure patch or dressing as prescribed.
Report changes in vital signs or the presence of bright red drainage on the pressure patch or dressing.
