A nurse is providing care for clients on a medical-surgical unit.
Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)

Choice A rationale

While it is understandable that a client with a patch on one eye after cataract surgery might express fear of falling due to altered depth perception, this comment reflects anxiety and a potential safety concern that the nurse should address with safety measures and reassurance, but it is not necessarily an unexpected complication requiring immediate reporting to the provider.

Choice B rationale

Reporting severe eye pain to the provider is crucial following cataract surgery. While some mild discomfort is expected, significant pain can indicate a potential complication such as increased intraocular pressure, infection (endophthalmitis), or corneal abrasion, all of which require prompt medical evaluation and intervention to prevent vision loss.

Choice C rationale

Mild itching after cataract surgery can be related to the healing process or the surgical dressing. Instructing the client not to rub the eye is appropriate to prevent infection or disruption of the surgical site. While the nurse should reinforce this instruction, the itching itself, without other signs of complications, does not necessarily warrant immediate reporting to the provider.

Choice D rationale

Sensitivity to bright light (photophobia) is a common occurrence after cataract surgery due to pupillary dilation during the procedure and the eye's adjustment to the new lens. Providing sunglasses or dimming the lights can help alleviate this discomfort. While the nurse should address this concern, it is a common and expected symptom that does not usually require immediate reporting to the provider unless it is severe or accompanied by other concerning symptoms. .

Choice A rationale

Nausea and vomiting are common side effects of morphine sulfate, an opioid analgesic administered via a PCA pump. An antiemetic medication directly addresses these symptoms and improves patient comfort.

Choice B rationale

Encouraging the use of an incentive spirometer is important for preventing postoperative respiratory complications, but it does not directly address the client's current nausea and vomiting.

Choice C rationale

Auscultating bowel sounds is important for assessing gastrointestinal function, but it does not provide immediate relief from nausea and vomiting. While changes in bowel sounds could indicate a problem, addressing the symptom with an antiemetic is the priority.

Choice D rationale

Inserting a nasogastric tube is an invasive procedure typically reserved for persistent vomiting, bowel obstruction, or gastric decompression. It is not the first-line intervention for nausea and vomiting related to opioid use.