A nurse is planning care for a client 1 day postoperative following a detached retinal repair.
Which of the following instructions should the nurse include?

Allow the client to ambulate.

Remove the eye patch during the day.

Encourage coughing and deep-breathing.

Avoid reading and writing.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Allowing the client to ambulate one day after a detached retinal repair is not recommended. Ambulation can increase intraocular pressure and disrupt the healing process of the retina. The client should be advised to limit physical activity to prevent any strain on the eye.

Choice B rationale

Removing the eye patch during the day is not advisable as it can expose the eye to potential injury or infection. The eye patch helps protect the eye and maintain the correct position for healing. It should be worn as directed by the healthcare provider.

Choice C rationale

Encouraging coughing and deep-breathing exercises is not appropriate for a client who has undergone retinal repair. These activities can increase intraocular pressure and risk detachment of the retina. The client should avoid activities that cause strain or pressure on the eyes.

Choice D rationale

Avoiding reading and writing is crucial for a client one day postoperative following a detached retinal repair. These activities can cause rapid eye movements and strain, which can interfere with the healing process and reattachment of the retina. The client should be advised to rest their eyes and avoid any activities that require intense focus or eye movement.

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Correct Answer is D

Explanation

Choice A rationale

Sound lateralizing to the right ear during the Rinne test does not indicate conductive hearing loss in the left ear. This result suggests that the right ear may have better hearing or that there is an issue with the left ear, but it does not specifically diagnose conductive hearing loss.

Choice B rationale

Sound lateralizing to the left ear during the Rinne test indicates that the left ear is perceiving the sound better, which could be due to conductive hearing loss in the left ear. However, this option does not provide a definitive result for conductive hearing loss.

Choice C rationale

Air conduction being greater than bone conduction in the left ear is a normal finding and does not indicate conductive hearing loss. In conductive hearing loss, bone conduction is typically better than air conduction.

Choice D rationale

Air conduction being less than bone conduction in the left ear is indicative of conductive hearing loss. This result means that the sound is being conducted through the bones of the skull more effectively than through the air, which is a hallmark of conductive hearing loss.

A. I need to drink room temperature beverages. B. I can take a prescribed analgesic to help manage the pain. C. I need to be careful not to spread this to my family. D. The chemotherapy affected my immune system.

Correct Answer is C

Explanation

Drinking room temperature beverages can help minimize irritation in the mouth and throat, which is beneficial for clients with stomatitis. Cold or hot beverages can exacerbate the condition by causing discomfort and pain.

Choice B rationale

Taking a prescribed analgesic can help manage the pain associated with stomatitis. Pain management is crucial for maintaining the client’s comfort and ability to eat and drink.

Choice C rationale

Stomatitis is not contagious and cannot be spread to family members. This statement indicates a need for further teaching as it reflects a misunderstanding of the condition.

Choice D rationale

Chemotherapy can affect the immune system, making the client more susceptible to infections and conditions like stomatitis. This statement is accurate and does not indicate a need for further teaching.

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A nurse is planning care for a client 1 day postoperative following a detached retinal repair. Which of the following instructions should the nurse include?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear?

Correct Answer is D

Explanation

A client diagnosed with bowel cancer has recently received a course of chemotherapy and has now developed stomatitis. The nurse provides instructions to the client regarding the condition and determines the need for further teaching if the client makes which statement?

Correct Answer is C

Explanation

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A nurse is planning care for a client 1 day postoperative following a detached retinal repair.
Which of the following instructions should the nurse include?