A nurse is providing teaching to a client following surgery to repair a detached retina of the left eye. Which of the following instructions should the nurse include in the teaching?

"Take a stool softener daily."

"You can lift objects that weigh 15 pounds."

"Avoid reading for 3 days following surgery."

"Pick up items by bending at the waist."

Answer and Explanation

The Correct Answer is A

Rationale:
A. "Take a stool softener daily.": Preventing straining during bowel movements is critical after retinal surgery because increased intraocular pressure from straining can disrupt the surgical repair. Stool softeners help maintain soft stools and reduce the risk of increased eye pressure.

B. "You can lift objects that weigh 15 pounds.": Clients should avoid heavy lifting after retinal surgery to prevent increased intraocular pressure. The amount of weight considered safe is minimal, and lifting anything heavier can compromise the surgical site.

C. "Avoid reading for 3 days following surgery.": Light visual activities like reading are usually permitted after surgery, depending on provider instructions. Complete restriction is unnecessary, though clients should avoid activities that increase eye strain or involve prolonged downward gaze.

D. "Pick up items by bending at the waist.": Bending at the waist increases intraocular pressure, which can compromise the retina. Clients should be instructed to bend at the knees and keep the head upright when picking up objects to protect the surgical repair.

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Correct Answer is C

Explanation

Rationale:
A. Perform range-of-motion exercises once per shift: While ROM exercises help maintain joint mobility, they are not a priority in the acute management of bacterial meningitis. The immediate focus is on preventing complications such as seizures and managing neurological status.

B. Place the client in high-Fowler's position: Although elevated head positioning can reduce intracranial pressure slightly, there is no strict requirement for high-Fowler’s positioning in bacterial meningitis. Comfort and safety are more important, with frequent neurological monitoring.

C. Implement seizure precautions: Bacterial meningitis increases the risk of seizures due to inflammation and increased intracranial pressure. Implementing seizure precautions—such as padding side rails, having suction available, and ensuring rapid access to emergency equipment—is a key safety measure.

D. Monitor the client for hypoglycemia: Hypoglycemia is not typically a complication of bacterial meningitis. Instead, monitoring focuses on neurological status, vital signs, fluid balance, and signs of increased intracranial pressure.

A. Prepare an IV bolus of dextrose 5% in water. B. Administer methylergonovine IM. C. Administer calcium gluconate IV. D. Position the client supine.

Correct Answer is C

Explanation

Rationale:
A. Prepare an IV bolus of dextrose 5% in water: Administering dextrose does not reverse magnesium sulfate toxicity. Dextrose primarily provides energy and fluid but has no effect on magnesium levels or neuromuscular function.

B. Administer methylergonovine IM: Methylergonovine is used to treat postpartum hemorrhage by promoting uterine contractions. It does not counteract magnesium toxicity and is unrelated to this emergency situation.

C. Administer calcium gluconate IV: Calcium gluconate is the antidote for magnesium sulfate toxicity. It works by antagonizing magnesium at neuromuscular junctions, reversing respiratory depression, hypotonia, and loss of deep tendon reflexes associated with toxicity.

D. Position the client supine: While client positioning may assist with comfort or circulation, supine positioning does not treat magnesium sulfate toxicity. The priority is administering the antidote to prevent further complications such as respiratory arrest.

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A nurse is providing teaching to a client following surgery to repair a detached retina of the left eye. Which of the following instructions should the nurse include in the teaching?

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