A nurse is caring for a client who is postoperative from glaucoma surgery in the right eye. Which of the following will the nurse include in the postoperative education to the client? (Select all that apply.)
You will be able to drive home right after you have voided.
Lay on the right side when going to bed.
Report flashing lights.
Nap on your left side when you get home.
Avoid housework like vacuuming.
Flashes of light are normal.
Correct Answer : C,E,F
Choice A reason: This is incorrect because the nurse should not include this in the postoperative education to the client. The client should not drive home after glaucoma surgery, as they will have reduced vision and increased sensitivity to light in the operated eye. The nurse should advise the client to arrange for someone else to drive them home.
Choice B reason: This is incorrect because the nurse should not include this in the postoperative education to the client. The client should not lay on the right side when going to bed, as this can put pressure on the operated eye and increase the risk of bleeding or infection. The nurse should advise the client to sleep on their back or on their left side.
Choice C reason: This is correct because the nurse should include this in the postoperative education to the client. The client should report flashing lights, as this can indicate a complication such as retinal detachment or vitreous hemorrhage. The nurse should instruct the client to call the provider immediately if they see flashing lights.
Choice D reason: This is incorrect because the nurse should not include this in the postoperative education to the client. The client should not nap on their left side when they get home, as this can cause fluid accumulation and increased intraocular pressure in the operated eye. The nurse should advise the client to elevate their head at least 30 degrees when resting.
Choice E reason: This is correct because the nurse should include this in the postoperative education to
the client. The client should avoid housework like vacuuming, as this can cause bending, lifting, or straining that can increase intraocular pressure and affect wound healing. The nurse should advise the client to limit physical activity and follow the provider's instructions on when to resume normal activities.
Choice F reason: This is correct because the nurse should include this in the postoperative education to
the client. The client may see flashes of light in the operated eye, as this is a normal phenomenon caused by stimulation of the retina by gas bubbles or fluid shifts. The nurse should reassure the client that flashes of light are normal and will subside over time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A Reason: A distended bladder is one of the most common triggers of autonomic dysreflexia, which is a life-threatening condition that occurs in clients with spinal cord injuries above T-6. The bladder becomes overfilled and stimulates the sympathetic nervous system, causing vasoconstriction and hypertension.
Choice B Reason: A severe headache is one of the most common symptoms of autonomic dysreflexia, caused by the increased blood pressure in the brain. The headache may be accompanied by blurred vision, sweating, flushing, or anxiety.
Choice C Reason: An elevated blood pressure is the hallmark sign of autonomic dysreflexia, which can reach dangerously high levels and cause stroke, seizure, or death. The blood pressure may rise up to 300/160 mmHg or higher.
Choice D Reason: Nasal congestion is another possible trigger of autonomic dysreflexia, as it stimulates the nasal mucosa and activates the sympathetic nervous system. Other potential triggers include bowel impaction, skin irritation, tight clothing, or temperature changes.
Correct Answer is C
Explanation
Choice A Reason: Inserting a nasal swab to observe the fluid is contraindicated, as it can introduce infection or increase intracranial pressure. The fluid can be tested for glucose or halo sign to confirm cerebrospinal fluid (CSF) leakage.
Choice B Reason: Suctioning the nose gently with a bulb syringe is also contraindicated, as it can create negative pressure and increase CSF leakage or cause meningitis.
Choice C Reason: This is the correct answer because allowing the drainage to drip onto a sterile gauze pad can prevent contamination and facilitate observation of the amount and characteristics of the fluid.
Choice D Reason: Inserting sterile packing into the nares is not recommended, as it can obstruct the drainage and increase intracranial pressure or infection risk.
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