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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Correct Answer is A

Explanation

A. Measure the duration of the seizure. This is the correct action. Monitoring the duration of the seizure is important for assessing its severity and deciding when to intervene medically. A seizure lasting longer than 5 minutes requires immediate intervention.

B. Lower the side rails of the bed when the seizure begins. This is not recommended. The side rails should be raised to protect the client from injury. Lowering them could increase the risk of falling out of bed.

C. Insert an oral airway into the client's mouth. This is incorrect. Inserting an airway into the mouth during a seizure can be dangerous and may result in injury to the client or the nurse. The client’s airway should be kept clear, but inserting an object into the mouth is not recommended.

D. Restrain the client's arms and legs to prevent injury. This is incorrect. Restraining the client during a seizure can cause injury to both the client and the nurse. It is better to allow the seizure to proceed naturally while ensuring the client is protected from injury (e.g., by placing a soft pillow under their head or cushioning hard surfaces around them).

A. Elevated blood pressure B. Bounding pulse C. Fruity breath odor D. Clammy skin

Correct Answer is C

Explanation

A. Elevated blood pressure: Diabetic ketoacidosis (DKA. typically does not cause elevated blood pressure. In fact, due to dehydration from increased urination, clients often present with hypotension or normal blood pressure, rather than hypertension.

B. Bounding pulse: A bounding pulse is not commonly associated with DKA. It may be seen with conditions such as fever or sepsis, but DKA is more likely to cause a weak or thready pulse due to fluid volume deficit and dehydration.

C. Fruity breath odor: A fruity or acetone-like breath odor is a hallmark sign of diabetic ketoacidosis. This is caused by the presence of ketones in the blood, which are produced as the body breaks down fat for energy when glucose is unavailable.

D. Clammy skin: Clammy skin is more likely to be associated with hypoglycemia, not DKA. In DKA, the skin is typically dry due to dehydration, and the client may appear flushed, not clammy.

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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 caring for a client who is in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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