A client is scheduled for a scleral buckling procedure after previously having multiple laser coagulation procedures done for retinal tears. Which Information about the immediate postoperative period should the nurse provide this client?
Report reoccurring visual signs of retinal detachment.
Maintain the head in one postoperative position.
Watch for signs of infection in the surgical eye.
Ambulate to the bathroom with assistance.
The Correct Answer is A
A. This is the most crucial information to provide. A scleral buckling procedure is performed to repair a retinal detachment. Any signs of detachment recurrence are critical and should be reported immediately. Directly addresses the primary goal of the surgery.
B. While maintaining the head in a specific position is often recommended post-surgery, it's not the most critical information in this context. The focus should be on identifying potential complications. Not as critical as the other options.
C. Infection is a potential complication of any surgery, but it's not the primary concern immediately post-scleral buckling. Important but not the most critical information.
D. Ambulation is generally encouraged to prevent complications like pneumonia and deep vein thrombosis, but it's not a specific concern immediately post-scleral buckling. Not directly related to the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Potential Condition
Poor healing of stage 2 pressure injury
The stage 2 pressure injury on the right trochanter with minimal drainage and pain suggests poor healing, which is often due to a combination of factors including immobility, malnutrition, and other risk factors. The Braden Scale score reflects several high-risk areas that contribute to the poor healing of the pressure injury.
Actions to Take
1. Apply pressure reduction mattress to bed
A pressure reduction mattress helps alleviate pressure on vulnerable areas and can significantly reduce the risk of further injury and promote healing. It is a crucial intervention for managing pressure injuries and preventing new ones.
2. Request service of wound care nurse
Consulting a wound care nurse can provide specialized assessment and treatment for the pressure injury. This professional can recommend advanced wound care techniques and products to support optimal healing and address any complications.
Parameters to Monitor
1. Progression of wound
Monitoring the progression of the wound involves assessing changes in size, depth, and appearance of the pressure injury. This helps evaluate the effectiveness of interventions and the rate of healing.
2. Adherence to repositioning schedule
Regular repositioning is crucial to relieve pressure on vulnerable areas and prevent further injury. Ensuring that the client is repositioned according to the schedule helps prevent pressure ulcers from worsening and supports healing.
Incorrect conditions
Immobility: Although immobility is a factor in pressure injuries, the direct intervention would be to improve mobility, not necessarily apply to the current situation.
Dehydration: While dehydration can affect skin health and healing, the primary condition here is the poor healing of the pressure injury rather than dehydration itself.
Malnutrition: Malnutrition can impair wound healing, but the immediate action would be more related to wound care and pressure relief. Nutrition might be addressed separately through dietary interventions.
Correct Answer is ["333"]
Explanation
One gram is equivalent to 1000 mg. If you add 2.5 mL of sterile water to the vial as instructed, the total volume of the solution becomes 3.0 mL.
Therefore, the concentration of the solution is 1000 mg divided by 3 mL, which equals approximately 333.33 mg/mL.
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