Retinal detachment

A nurse is caring for a client who underwent emergency retinal detachment repair surgery 6 hours ago. Which assessment finding requires the most immediate nursing intervention?

Post-operative retinal detachment repair assessment priorities

1 Client reports mild eye pain rated 3/10 on pain scale
2 Small amount of clear drainage noted on eye dressing
3 Client's blood pressure is 138/82 mmHg
4 Client reports sudden onset of flashing lights and new floaters in the operative eye ✓ 정답

해설

Sudden onset of flashing lights and new floaters indicates potential retinal re-detachment or new tears, an emergency requiring immediate intervention to prevent permanent vision loss. Mild pain, clear drainage, and slightly elevated BP are less urgent findings.

같은 주제 다음 문제A nurse is assessing a client who reports sudden onset of visual disturbances. Which asses…이 문제가 수록된 문제집[개념+기출] 엔클렉스(NCLEX), 이거 하나면 됩니다69,000원

Understanding the Priority: Retinal Re-Detachment

The most critical assessment finding requiring immediate intervention is the client's report of sudden onset of flashing lights (photopsia) and new floaters in the operative eye. In the context of a recent retinal detachment repair, this symptom cluster is the classic presentation of a recurrent retinal detachment or a new retinal tear. A retinal detachment is an ophthalmic emergency because it can lead to permanent vision loss if not promptly addressed ^[1]. The pathogenesis involves the separation of the neurosensory retina from the underlying retinal pigment epithelium, which, if left untreated, results in photoreceptor death and irreversible blindness ^[1]. The sudden reappearance of these specific visual disturbances indicates active vitreoretinal traction and a new or progressing break, demanding an immediate evaluation by the surgeon to preserve the client's vision.

Analysis of Incorrect Options

- Option 1: A report of mild eye pain rated 3/10 is an expected finding 6 hours post-operatively. While pain management is a nursing responsibility, it does not signal a sight-threatening complication like a recurrent detachment.
- Option 2: A small amount of clear drainage on the eye dressing is a common and anticipated post-operative finding. This is typically serous fluid and does not require immediate intervention beyond routine monitoring and documentation. It does not indicate an acute pathological process.
- Option 3: A blood pressure of 138/82 mmHg is mildly elevated but is not the most immediate threat in this scenario. While hypertension can contribute to bleeding and should be reported, it does not carry the same time-sensitive, sight-threatening urgency as symptoms of a recurrent retinal detachment. The sudden onset of visual symptoms directly related to the surgical site takes precedence.

Clinical Reasoning and Pathophysiology

The priority setting in this post-operative scenario is guided by the principle of airway, breathing, circulation, and then disability (including sensory function like vision). A recurrent rhegmatogenous retinal detachment (RRD) is an acute threat to vision, which is a critical sensory function. The prognosis for visual recovery after RRD repair is significantly influenced by the timeliness of intervention and whether the macula remains attached . A study on prognostic factors after RRD repair highlights that visual outcomes are closely tied to the pre-operative status of the retina, particularly macular involvement . The client's report of new floaters and flashing lights strongly suggests a new or extending retinal break with vitreous traction, which can rapidly progress to involve the macula (macula-off detachment), leading to a poorer visual prognosis . Therefore, this finding is the most urgent because the window for effective intervention to preserve central visual acuity is extremely narrow.

References (research sources)

[1]
A review of rhegmatogenous retinal detachment: past, present and future.Research articleXiong J, Tran T, Waldstein SM, Fung AT. (2025) · DOI: 10.1007/s10354-025-01085-9

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A nurse is caring for a client who underwent emergency retinal detachment repair surgery 6 hours ago. Which assessment finding requires the most immediate nursing intervention?

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