An older adult client with a history of cataracts is recovering from intraocular lens implant (IOL) surgery to the left eye. During the postprocedure period, which intervention should the nurse implement?

Provide an eye shield to be worn while sleeping.

Teach a family member to administer eye drops.

Obtain vital signs every 2 hours during hospitalization.

Encourage deep breathing and coughing exercises.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Provide an eye shield to be worn while sleeping: After intraocular lens implant surgery, an eye shield protects the operated eye from accidental trauma, rubbing, or pressure during sleep. This intervention helps prevent increases in intraocular pressure and supports proper healing of the surgical site.

B. Teach a family member to administer eye drops: While instructing caregivers on postoperative eye drop administration is important, it is not the immediate intervention during the initial postprocedure period. Eye protection takes priority to prevent injury.

C. Obtain vital signs every 2 hours during hospitalization: Routine vital sign monitoring is important but does not directly prevent complications specific to intraocular surgery. Frequent vitals are not required unless the client has additional comorbidities or complications.

D. Encourage deep breathing and coughing exercises: While these exercises support pulmonary function, they can temporarily increase intraocular pressure. Immediate postoperative care focuses on protecting the surgical site, making these exercises less appropriate initially.

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Correct Answer is A

Explanation

Rationale:
A. Notify the stroke team to assist with acute assessment and management: Sudden unilateral weakness and facial droop indicate an acute stroke, requiring rapid, coordinated intervention. Activating the stroke team ensures timely neurologic assessment, imaging interpretation, and determination of eligibility for thrombolytic or endovascular therapy. Early team involvement is critical to minimizing neuronal injury and improving outcomes.

B. Keep the bed in the lowest position and initiate seizure and fall precautions: Safety measures are important but do not address the immediate need for rapid stroke evaluation and treatment. Delaying definitive stroke management can result in loss of critical treatment time. These precautions can be implemented after urgent stroke protocols are underway.

C. Administer aspirin to prevent further clot formation and platelet clumping: Aspirin is contraindicated until intracranial hemorrhage has been ruled out by CT imaging. Premature antiplatelet administration could worsen bleeding if a hemorrhagic stroke is present. Medication decisions must follow diagnostic confirmation.

D. Test for a swallowing reflex and perform communication deficit assessments: Swallowing and communication assessments are part of comprehensive stroke care but are not the immediate priority in the hyperacute phase. These evaluations are performed after stabilization and initial management decisions. Rapid activation of stroke protocols takes precedence.

A. Schedule a daily conference with the social worker. B. Encourage the client's family to visit more often. C. Encourage the client to participate in group activities. D. Engage the client in non-threatening conversations.

Correct Answer is D

Explanation

Rationale:
A. Schedule a daily conference with the social worker: While involving the social worker may help address psychosocial needs, it does not directly engage the client or address withdrawal and communication difficulties on a day-to-day basis.

B. Encourage the client's family to visit more often: Family visits can provide support, but some clients with depression may feel overwhelmed or withdraw further. This approach may not immediately improve engagement or communication.

C. Encourage the client to participate in group activities: Group participation can be beneficial, but withdrawing clients may feel pressured or anxious in group settings, making this intervention less effective initially.

D. Engage the client in non-threatening conversations: Gentle, supportive one-on-one communication helps build trust, encourages expression of feelings, and can gradually reduce social withdrawal. This approach directly addresses the client’s current behavior and is a priority nursing intervention.

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An older adult client with a history of cataracts is recovering from intraocular lens implant (IOL) surgery to the left eye. During the postprocedure period, which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse notes that a client with depression has been more withdrawn and non communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

Correct Answer is D

Explanation

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