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. An anaphylactic reaction is correct. Symptoms such as urticaria (hives) and wheezing indicate a severe allergic reaction, which can progress to anaphylaxis. This reaction is caused by a hypersensitivity to plasma proteins in the transfused blood and requires immediate intervention, including stopping the transfusion and administering epinephrine.

B. An acute hemolytic reaction is incorrect. This reaction occurs when the recipient's immune system attacks incompatible donor red blood cells, leading to symptoms such as fever, chills, flank pain, hypotension, and hemoglobinuria. Urticaria and wheezing are not characteristic symptoms of this reaction.

C. A febrile reaction is incorrect. Febrile reactions are the most common type of transfusion reaction and are typically characterized by fever, chills, and headache, rather than urticaria or wheezing.

D. Circulatory overload is incorrect. This reaction occurs when too much fluid is infused too quickly, leading to dyspnea, hypertension, and pulmonary edema. While respiratory distress can occur, it is not accompanied by urticaria, which is specific to an allergic reaction.

A. A client who has a sodium intake of 1,200 mg/day. B. A client who has a serum albumin level of 4.5 g/dL. C. A client who has a body mass index of 32. D. A client who has a total fat intake of 25% of daily calories.

Correct Answer is C

Explanation

A. A client who has a sodium intake of 1,200 mg/day.: A sodium intake of 1,200 mg/day is actually within the recommended range for most adults. Therefore, this client does not require a dietitian’s consultation based on this information alone.

B. A client who has a serum albumin level of 4.5 g/dL.: A serum albumin level of 4.5 g/dL is within the normal reference range. There is no immediate concern with this level, so an interprofessional care conference is not necessary for this client.

C. A client who has a body mass index of 32.: A BMI of 32 is classified as obese, which can increase the risk of various health problems. A dietitian’s input can help address dietary modifications to manage weight and improve health outcomes, making an interprofessional care conference appropriate.

D. A client who has a total fat intake of 25% of daily calories.: A fat intake of 25% is within the acceptable range for most adults and does not immediately warrant a referral to a dietitian unless there are other concerns.

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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 monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?

Correct Answer is A

Explanation

A nurse is collecting nutritional data from a group of adult clients. For which of the following clients should the nurse recommend an interprofessional care conference with a dietitian?

Correct Answer is C

Explanation

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