A nurse is assisting with discharge teaching for a client who is postoperative following the repair of a detached retina. Which of the following instructions should the nurse include in the teaching?

"You can take a stool softener to prevent constipation."

"You can remove your eye patch during the day."

"You should bend from the waist to pick up objects."

"You can apply a warm, moist compress to your forehead to reduce pain."

Answer and Explanation

The Correct Answer is A

A. "You can take a stool softener to prevent constipation." is correct. After a retinal detachment repair, clients should avoid straining during bowel movements, as increased intracranial pressure could affect the healing eye. Taking a stool softener is a helpful preventive measure to avoid constipation.

B. "You can remove your eye patch during the day." is incorrect. The eye patch should typically be worn continuously to protect the eye and support healing. The surgeon's specific instructions should be followed regarding when the patch can be removed.

C. "You should bend from the waist to pick up objects." is incorrect. After retinal surgery, clients should avoid bending from the waist as this can increase intraocular pressure, potentially compromising the surgical repair. Instead, clients should use proper body mechanics and bend at the knees.

D. "You can apply a warm, moist compress to your forehead to reduce pain." is incorrect. Applying a warm compress to the forehead is not typically recommended following a retinal repair. Clients should follow the specific post-operative instructions from the surgeon, which may include cold compresses or other methods of managing discomfort.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Having the client point his toes before inserting his foot into the stocking is incorrect. The nurse should instruct the client to keep the foot in a neutral position to avoid unnecessary pressure on the toes or veins.

B. Removing the stockings once every 24 hr is incorrect. Antiembolic stockings should typically be removed and reapplied at least once per shift to allow for skin assessment and hygiene. They should not remain on for 24 hours continuously.

C. Elevating the client's legs for 5 min prior to applying the stockings is correct. Elevating the legs helps promote venous return by reducing swelling in the lower extremities. This makes the application of antiembolic stockings more effective and more comfortable for the client.

D. Rolling the top of the stocking down so it fits snugly above the client's calf is incorrect. The stockings should be applied smoothly and without folds to avoid restricting circulation. The top should not be rolled down as it can create pressure points

A. Tonic-clonic seizures B. Paresthesias C. Disorientation D. Sleep apnea

Correct Answer is C

Explanation

A. Tonic-clonic seizures: This is not typically expected following electroconvulsive therapy (ECT). ECT can induce a brief seizure during the procedure, but the nurse would not expect tonic-clonic seizures afterward as a direct result.

B. Paresthesias: Paresthesias (tingling or numbness) are not commonly associated with ECT. The procedure primarily affects the brain, and while some neurological symptoms may occur temporarily, paresthesias are not expected findings.

C. Disorientation: This is correct. It is common for clients to experience disorientation and confusion immediately following ECT, as it can affect memory and cognition temporarily. This typically resolves within a short period of time (minutes to hours) following the procedure.

D. Sleep apnea: Sleep apnea is not a direct or common effect of ECT. While anesthesia used during the procedure may cause some temporary respiratory changes, sleep apnea would not be expected as a typical post-procedure finding.

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A nurse is assisting with discharge teaching for a client who is postoperative following the repair of a detached retina. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is applying antiembolic stockings for a client who is postoperative. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following the procedure?

Correct Answer is C

Explanation

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