# 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?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=541576  
> language: ko  
> subject: Adult Health

## 문제

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?

## 보기

1. Client reports mild eye pain rated 4/10
2. Small amount of clear drainage from the surgical site
3. Sudden onset of severe eye pain with nausea and vomiting **✔ 정답**
4. Slight decrease in visual acuity compared to pre-operative baseline

**정답: 3**

## 해설

Sudden onset of severe eye pain with nausea and vomiting indicates increased intraocular pressure, a vision-threatening emergency requiring immediate intervention. Mild pain, clear drainage, and slight vision changes are expected post-operative findings manageable with standard care.

## 심화 해설

Understanding the Clinical Scenario

The client is 6 hours post-operative from emergency retinal detachment repair. This is a critical period where the retina is beginning to reattach, and the intraocular pressure (IOP) is stabilizing. The nurse must differentiate between expected post-surgical findings and signs of a serious complication that threatens vision.

Analysis of Assessment Findings

The correct answer is the sudden onset of severe eye pain with nausea and vomiting. This cluster of symptoms is a classic presentation of acute angle-closure glaucoma, a devastating complication that can occur after intraocular surgery. The underlying mechanism is a rapid, severe elevation in IOP. The provided research highlights that postoperative elevation of intraocular pressure (IOP) is a known adverse effect following vitreoretinal procedures [1]. When IOP rises abruptly, it stimulates the oculocardiac reflex and triggers intense pain and vagal symptoms like nausea and vomiting. This constitutes an ocular emergency requiring immediate intervention to prevent irreversible optic nerve damage and permanent vision loss.

Why the Other Options Are Less Urgent

- Mild eye pain rated 4/10: This is an expected finding after surgery. The sclera and surrounding tissues have been manipulated, and some degree of discomfort is normal. It requires ongoing monitoring and pain management but is not the priority.

- Small amount of clear drainage: A small amount of serous, clear drainage can be a normal post-operative finding, representing weeping of the conjunctival tissue. The nurse should note its characteristics and monitor for changes, but it does not signal an immediate threat.

- Slight decrease in visual acuity: Immediately after retinal surgery, vision is often worse than the pre-operative baseline due to surgical trauma, inflammation, gas or oil tamponade, and blood in the vitreous. The research notes that thinning of the ganglion cell complex (GCC) and other structural changes can adversely affect visual outcomes [1]. A slight decrease is expected and will be monitored over the recovery period; it does not require the same instantaneous response as a pressure crisis.

Pathophysiology and Clinical Priority

The sudden, severe pain is the body's direct response to a rapid IOP spike, which mechanically stresses the ocular structures. The accompanying nausea and vomiting are a systemic vagal response to this intense pain. This combination is a red flag for acute glaucoma, which can be triggered post-operatively by inflammation, pupillary block, or the use of intraocular gas or oil. The research confirms that altered ocular biomechanics and inflammation are key factors in post-vitrectomy IOP changes [1]. The nurse's immediate priority is to recognize this as an emergency, notify the surgeon, and prepare for interventions to rapidly lower the IOP, such as administering prescribed hyperosmotic agents or topical medications.References (research sources)

- [1]Changes in Intraocular Pressure and Ganglion Cell Complex Thickness After Pars Plana Vitrectomy in Patients With and Without Diabetes Mellitus.Research articleN S, Mohanty G, Das MK, Mohanty S, Singhal A, Choudhary M. (2026) · DOI: 10.7759/cureus.107201

## 임상 시나리오

Post-Vitrectomy Emergency AssessmentRecognizing Acute Angle-Closure Glaucoma
The classic triad of acute angle-closure glaucoma is sudden, severe eye pain, nausea/vomiting, and blurred vision with a fixed, mid-dilated pupil. This reflects a rapid IOP spike, often exceeding 40 mmHg.

Postoperative IOP elevation is a known risk after vitreoretinal surgery. Immediate assessment includes checking IOP via tonometry and inspecting the anterior chamber depth.

CautionDo not confuse this with expected post-op discomfort. Severe pain with vagal symptoms is an ocular emergency. Delay in lowering IOP can cause irreversible optic nerve damage within hours.

## 핵심 개념

- **Acute Angle-Closure Glaucoma** — A rapid, severe elevation in intraocular pressure causing sudden eye pain, nausea, vomiting, and blurred vision; an ocular emergency requiring immediate intervention to prevent optic nerve damage.
- **Intraocular Pressure (IOP)** — The fluid pressure inside the eye; normal range is 10-21 mmHg. Postoperative spikes can occur after vitreoretinal procedures and threaten vision.
- **Oculocardiac Reflex** — A vagal response triggered by pressure on the eye or extraocular muscles, leading to bradycardia, nausea, and vomiting.

## 같은 주제 문제

- [A nurse is assessing a client who reports sudden onset of visual disturbances. Which asses…](https://mymerci.kr/pages/nclex_q.php?qn_id=541568)
- [A nurse is assessing a patient who reports sudden onset of visual disturbances. Which asse…](https://mymerci.kr/pages/nclex_q.php?qn_id=541569)
- [A nurse is caring for a client who underwent emergency scleral buckling surgery for retina…](https://mymerci.kr/pages/nclex_q.php?qn_id=541570)
- [A nurse is caring for a 58-year-old client who presents to the emergency department with s…](https://mymerci.kr/pages/nclex_q.php?qn_id=541571)
- [A nurse is caring for a client who underwent emergency surgery for retinal detachment repa…](https://mymerci.kr/pages/nclex_q.php?qn_id=541572)
- [A nurse is caring for a client who reports sudden onset of flashing lights and a "curtain-…](https://mymerci.kr/pages/nclex_q.php?qn_id=541573)
- [A 58-year-old client presents to the emergency department with sudden onset of flashing li…](https://mymerci.kr/pages/nclex_q.php?qn_id=541574)
- [A nurse is caring for a client who underwent emergency retinal detachment repair surgery 6…](https://mymerci.kr/pages/nclex_q.php?qn_id=541575)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._