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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

Direct identification of the causative organism: A culture for sensitive organisms is the most direct and definitive way to identify the specific bacteria or other microorganisms that are causing the infection in the wound. This information is crucial for guiding the selection of the most appropriate antibiotic therapy.

Tailored antibiotic therapy: By knowing the exact organism responsible, healthcare providers can prescribe antibiotics that are specifically effective against that organism, ensuring optimal treatment and reducing the risk of antibiotic resistance.

Informed infection control measures: The results of the culture can also inform appropriate infection control measures to prevent the spread of the infection to other patients or healthcare workers.

Monitoring treatment effectiveness: Cultures can also be used to monitor the effectiveness of antibiotic therapy. If the culture results show that the bacteria are no longer present after a course of antibiotics, this indicates that the treatment has been successful.

Choice B rationale:

Non-specific marker of inflammation: C-reactive protein (CRP) is a non-specific marker of inflammation that can be elevated in various conditions, including infections, but also in non-infectious conditions such as autoimmune diseases and trauma.

Limited diagnostic value for wound infections: While an elevated CRP level may suggest the presence of an infection, it does not provide information about the specific causative organism, which is essential for guiding antibiotic therapy.

Supplementary role: CRP levels can be used in conjunction with other clinical findings and laboratory tests to assess the severity of an infection and monitor the response to treatment, but it should not be relied upon as a sole diagnostic tool for wound infections.

Choice C rationale:

Not directly indicative of wound infection: Blood pH level primarily reflects the acid-base balance of the body and is not directly indicative of a wound infection.

Alterations in other conditions: Blood pH can be altered in various conditions, including respiratory and metabolic disorders, and is not specific to wound infections.

Limited role in diagnosis: While significant alterations in blood pH may suggest a serious systemic infection, it does not provide information about the location or causative organism of the infection.

Choice D rationale:

Not directly related to wound infection: Serum blood glucose level is primarily used to monitor diabetes and is not directly related to wound infections.

Impaired wound healing in diabetes: While elevated blood glucose levels can impair wound healing and increase the risk of infections in diabetic patients, it is not a diagnostic test for wound infections in general.

Secondary consideration: Blood glucose levels may be considered as part of the overall assessment of a patient with a wound infection, particularly in those with diabetes, but it is not a primary diagnostic tool.

A. Stat ventilation/perfusion (V/Q) of chest. B. Place patient on oxygen 2 to 4 liters and maintain oxygen saturation at or above 95%. C. Stat 2 views chest x-ray. D. Send sputum for culture & sensitivity stat. E. Complete blood count (CBC), basic metabolic panel (BMP), and blood cultures. F. Start the patient on antibiotic therapy.

Correct Answer is ["B","C","E","F"]

Explanation

B. Place patient on oxygen 2 to 4 liters and maintain oxygen saturation at or above 95%.

Rationale:

Hypoxemia: Patients who have undergone cholecystectomy are at risk for developing hypoxemia due to various factors, including:

Atelectasis: Collapsed lung tissue can impair gas exchange, leading to low oxygen levels in the blood.

Pneumonia: A potential post-operative complication that can cause inflammation and fluid buildup in the lungs, hindering oxygen uptake.

Pain: Post-surgical pain can inhibit deep breathing and coughing, which are essential for maintaining adequate lung function.

Oxygen Therapy: Supplementing oxygen helps to increase oxygen saturation and improve overall tissue oxygenation, reducing the strain on the heart and other organs.

Oxygen Saturation Goal: Maintaining oxygen saturation at or above 95% ensures that the patient's tissues are receiving sufficient oxygen to meet their metabolic needs.

C. Stat 2 views chest x-ray.

Rationale:

Chest X-ray: A valuable diagnostic tool that can visualize the lungs and surrounding structures, aiding in the assessment of: Atelectasis: Appears as areas of increased density on the x-ray, indicating collapsed lung tissue.

Pneumonia: May present as consolidation (solid white areas) or infiltrates (patchy areas of increased density) on the x-ray. Pleural effusion: Fluid accumulation in the pleural space, which can impair lung expansion and gas exchange.

Pneumothorax: Presence of air in the pleural space, which can cause lung collapse and respiratory distress.

Early Detection: Prompt identification of respiratory complications through chest x-ray allows for timely interventions and prevents further deterioration of the patient's condition.

E. Complete blood count (CBC), basic metabolic panel (BMP), and blood cultures.

Rationale:

CBC: Assesses for signs of infection or inflammation, including:

Elevated white blood cell count (leukocytosis) Increased neutrophils (neutrophilia)

Anemia (low red blood cell count)

BMP: Evaluates electrolyte and kidney function, which can be affected by infections and post-operative complications.

Blood Cultures: Determines the presence of bacteria in the bloodstream, allowing for identification of the causative organism and guiding appropriate antibiotic therapy.

F. Start the patient on antibiotic therapy.

Rationale:

Infection Risk: The patient's history of cholangitis and recent surgery increase the risk of infection. Prophylactic Antibiotics: Often administered after cholecystectomy to prevent post-operative infections.

Early Intervention: Prompt initiation of antibiotic therapy is crucial in managing infections and preventing serious complications such as sepsis.

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A client is recovering from the surgical removal of glass in the right eye.Which intervention should the nurse implement immediately following the procedure?

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Explanation

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A client is recovering from the surgical removal of glass in the right eye.
Which intervention should the nurse implement immediately following the procedure?