A client is recovering from the surgical removal of glass in the right eye.
Which intervention should the nurse implement immediately following the procedure?
Encourage deep breathing and coughing exercises.
Obtain vital signs every 2 hours during hospitalization.
Provide an eye shield to be worn while sleeping.
Teach a family member to administer eye drops.
The Correct Answer is C
Choice A rationale:
Deep breathing and coughing exercises are not a priority intervention immediately following eye surgery. They are more commonly used to prevent postoperative pulmonary complications, such as pneumonia or atelectasis, in patients who have undergone general anesthesia or have respiratory conditions.
While deep breathing and coughing exercises can help promote circulation and prevent blood clots, they are not directly relevant to protecting the eye after surgery.
Engaging in deep breathing and coughing exercises too soon after eye surgery could potentially increase intraocular pressure, which could strain the healing eye and potentially lead to complications.
Choice B rationale:
Obtaining vital signs every 2 hours is a standard nursing intervention for monitoring a patient's overall condition, but it is not the most immediate priority following eye surgery.
Vital signs can provide important information about the patient's heart rate, blood pressure, respiratory rate, and temperature, but they do not directly address the protection of the surgically treated eye.
While monitoring vital signs is important, it does not specifically address the prevention of injury or complications to the eye itself.
Choice C rationale:
Providing an eye shield is the most crucial intervention to protect the eye immediately following surgery. The eye shield serves several important purposes:
Protection from accidental injury: It prevents the patient from accidentally rubbing or bumping the eye during sleep, which could cause further damage or disrupt the healing process.
Prevention of infection: It helps to keep the eye clean and free from debris, reducing the risk of infection. Reduction of swelling: It can help to minimize swelling and discomfort by applying gentle pressure to the eye area.
Promotion of healing: By creating a dark and protected environment, the eye shield can promote rest and healing of the tissues.
Choice D rationale:
Teaching a family member to administer eye drops is an important intervention for long-term care, but it is not the most immediate priority following surgery.
The patient may be able to administer eye drops independently, or a nurse may be responsible for administering them in the initial post-operative period.
Focusing on teaching family members about eye drop administration right after surgery could distract from more urgent priorities, such as protecting the eye with an eye shield.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Incorrect. The kidneys do play a role in acid-base balance, but they primarily eliminate acids other than carbon dioxide. They do not significantly convert carbon dioxide for elimination.
Elaboration: While the kidneys help regulate acid-base balance through reabsorption and excretion of bicarbonate and hydrogen ions, their role in carbon dioxide elimination is minimal. They primarily excrete acids like uric acid, phosphoric acid, and lactic acid.
Choice B rationale:
Incorrect. Hyperventilation would decrease carbon dioxide levels, not contribute to respiratory acidosis. Respiratory acidosis is characterized by elevated carbon dioxide levels.
Elaboration: Hyperventilation leads to rapid and excessive breathing, causing a decrease in carbon dioxide levels in the blood. This can result in respiratory alkalosis, not respiratory acidosis.
Choice C rationale:
Correct. Respiratory acidosis is caused by the accumulation of carbon dioxide in the blood. This can happen due to impaired ventilation, such as in conditions like chronic obstructive pulmonary disease (COPD), pneumonia, or respiratory failure.
Elaboration: Carbon dioxide is produced as a byproduct of cellular metabolism. It is normally removed from the body through exhalation. When ventilation is impaired, carbon dioxide cannot be efficiently eliminated, leading to its buildup in the blood. This excess carbon dioxide reacts with water to form carbonic acid, lowering blood pH and causing respiratory acidosis.
Choice D rationale:
Incorrect. Low blood oxygen levels (hypoxemia) can stimulate the respiratory rate, but this would not directly cause respiratory acidosis. It might lead to hyperventilation, which could potentially cause respiratory alkalosis.
Elaboration: The body's respiratory center in the brainstem regulates breathing based on blood oxygen and carbon dioxide levels. Hypoxemia triggers a compensatory increase in respiratory rate to enhance oxygen intake. However, this response does not directly contribute to respiratory acidosis.
Correct Answer is B
Explanation
Choice A rationale:
While teaching the client about infection prevention measures is important, it is not the most crucial action in this situation. The client is already exhibiting symptoms and has potentially been spreading the virus.
Focusing on isolation at this point is a more effective way to prevent further transmission.
Additionally, the client may be too ill to fully comprehend or adhere to instructions regarding masks, handwashing, and social distancing.
Choice B rationale:
Isolation is the most essential action to prevent the spread of COVID-19 to others. This is because:
COVID-19 is highly contagious and can spread through respiratory droplets produced when an infected person coughs, sneezes, or talks.
Isolation physically separates the infected person from others, reducing the risk of transmission.
Proper PPE, such as gloves, gowns, masks, and eye protection, creates a barrier between the healthcare worker and the infectious droplets, further minimizing the risk of spread.
Choice C rationale:
Reporting the COVID-19 result to the local health department is important for tracking and managing the spread of the virus. However, it is not as immediate a priority as isolating the client to prevent further transmission.
Choice D rationale:
Counseling family members about monitoring for symptoms is also important for early identification and containment of potential cases. However, it does not directly address the immediate risk of transmission from the actively symptomatic client.
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