An older adult client is having photocoagulation for macular degeneration. Which intervention should the nurse implement during the postprocedure care in the outpatient surgical unit?

Apply bilateral eye patches while sleeping.

Arrange food on the plate in clockwise order.

Verbally identify self when entering the room.

Use a white board to communicate ideas.

Answer and Explanation

The Correct Answer is C

Rationale:
A. Apply bilateral eye patches while sleeping: Routine patching is not typically required after photocoagulation. This intervention may impair safety and independence unnecessarily, especially if only one eye was treated.

B. Arrange food on the plate in clockwise order: This technique supports clients with total blindness, but photocoagulation for macular degeneration usually preserves peripheral vision. Clock-face plate arrangement may not be necessary for partial vision loss.

C. Verbally identify self when entering the room: Clients with macular degeneration often lose central vision but retain peripheral vision. Verbal identification helps orient and reassure the client, supporting emotional comfort and safety in the postoperative period.

D. Use a white board to communicate ideas: White boards require intact central vision for reading. Clients with macular degeneration may struggle to see text, so verbal communication is generally more effective and appropriate.

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Correct Answer is A

Explanation

Rationale:

A. She is a gravida 6, para 5: A high parity (multiple previous births) stretches the uterus significantly over time, increasing the risk of uterine atony—a leading cause of postpartum hemorrhage due to the uterus failing to contract effectively.

B. She received butorphanol 2 mg IV during labor: Butorphanol is a narcotic analgesic and does not directly contribute to excessive postpartum bleeding or uterine atony in typical doses.

C. She is over 35 years of age: Advanced maternal age can increase some obstetric risks, but it is not as directly associated with postpartum hemorrhage as high parity.

D. The second stage of labor lasted 10 minutes: A short second stage may lead to perineal trauma, but it is less likely to cause excessive vaginal bleeding compared to uterine atony from high parity.

A. Monitor amount of intake and infant's response to feedings. B. Mark an outline of the "olive-shaped" mass in the right epigastric area. C. Instruct parents regarding care of the incisional area. D. Initiate a continuous infusion of IV fluids per prescription.

Correct Answer is D

Explanation

Rationale:

A. Monitor amount of intake and infant's response to feedings: Feeding issues are a hallmark of pyloric stenosis, but by the time surgery is scheduled, feedings are typically withheld. This is useful earlier in the diagnosis, but not the top priority just before surgery.

B. Mark an outline of the "olive-shaped" mass in the right epigastric area: Palpation of the mass is diagnostic but not relevant once the diagnosis is confirmed and surgery is planned. It offers no clinical benefit at the pre-operative stage.

C. Instruct parents regarding care of the incisional area: Parental teaching is important, but it is more appropriate after the procedure. The infant’s immediate physiological stability takes precedence before surgery.

D. Initiate a continuous infusion of IV fluids per prescription: Infants with pyloric stenosis often experience vomiting, leading to dehydration and electrolyte imbalances (e.g., hypokalemia, hypochloremia). Restoring fluid and electrolyte balance is the highest priority before surgery to ensure safety under anesthesia.

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An older adult client is having photocoagulation for macular degeneration. Which intervention should the nurse implement during the postprocedure care in the outpatient surgical unit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a recently delivered, multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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