An older adult client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?

Encourage deep breathing and coughing exercises.

Teach a family member to administer eye drops.

Provide an eye shield to be worn while sleeping

Obtain vital signs every 2 hours during hospitalization.

Answer and Explanation

The Correct Answer is C

A.   Deep breathing and coughing are important for general postoperative care but they are not specifically indicated for immediate postoperative cataract surgery. These exercises can increase intraocular pressure and potentially disrupt the healing process.
B.   While it's important to educate caregivers about medication administration, this is not the priority in the immediate postoperative period. The patient should be stable and comfortable before teaching begins.
C.   An eye shield is crucial to protect the operated eye from accidental injury during sleep. It prevents rubbing and potential complications.
D.   Monitoring vital signs is essential for postoperative care. However, the frequency of every 2 hours is excessive for cataract surgery. Vital signs can be monitored less frequently, depending on the patient's condition.

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Correct Answer is []

Explanation

Potential Condition
Poor healing of stage 2 pressure injury
The stage 2 pressure injury on the right trochanter with minimal drainage and pain suggests poor healing, which is often due to a combination of factors including immobility, malnutrition, and other risk factors. The Braden Scale score reflects several high-risk areas that contribute to the poor healing of the pressure injury.
Actions to Take

1. Apply pressure reduction mattress to bed
A pressure reduction mattress helps alleviate pressure on vulnerable areas and can significantly reduce the risk of further injury and promote healing. It is a crucial intervention for managing pressure injuries and preventing new ones.
2. Request service of wound care nurse
Consulting a wound care nurse can provide specialized assessment and treatment for the pressure injury. This professional can recommend advanced wound care techniques and products to support optimal healing and address any complications.
Parameters to Monitor

1. Progression of wound
Monitoring the progression of the wound involves assessing changes in size, depth, and appearance of the pressure injury. This helps evaluate the effectiveness of interventions and the rate of healing.
2. Adherence to repositioning schedule

Regular repositioning is crucial to relieve pressure on vulnerable areas and prevent further injury. Ensuring that the client is repositioned according to the schedule helps prevent pressure ulcers from worsening and supports healing.
Incorrect conditions

Immobility: Although immobility is a factor in pressure injuries, the direct intervention would be to improve mobility, not necessarily apply to the current situation.
Dehydration: While dehydration can affect skin health and healing, the primary condition here is the poor healing of the pressure injury rather than dehydration itself.
Malnutrition: Malnutrition can impair wound healing, but the immediate action would be more related to wound care and pressure relief. Nutrition might be addressed separately through dietary interventions.

A. Report of bowel functioning since surgery. B. Heart rate and body weight. C. Number of any missed doses of medication. D. Daily caloric intake.

Correct Answer is B

Explanation

A. While bowel function can be affected by medication, it's not a primary indicator of thyroid hormone replacement effectiveness.
B. These are the most important assessments to determine the effectiveness of thyroid replacement therapy. Thyroid hormones influence metabolic rate, which directly affects heart rate and body weight. Changes in these parameters can indicate under- or over-replacement of thyroid hormones.
C. While medication adherence is important, it doesn't directly assess the medication's effectiveness.
D. Dietary intake is important for overall health but is not directly related to thyroid hormone replacement therapy effectiveness.

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An older adult client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

A client receiving thyroid replacement therapy following a thyroidectomy is seen in the dinic for a 6 weeks postoperative check-up. Which assessment is most important for the nurse to obtain?

Correct Answer is B

Explanation

The nurse is collecting a urine specimen for a client with symptoms related to urethritis. Which collection method should the nurse implement?

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While assessing a client with type 2 diabetes mellitus (DM), the nurse observes an absence of hair growth on the client's lower legs. Which assessment provides further data to support this finding?

Which nursing action is most helpful in promoting circulation in a client with chronic venous insufficiency?

The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?