For a client who has undergone surgery to repair a retinal detachment in the left eye, which intervention should the nurse implement during the postoperative period?

Obtain vital signs every 2 hours during hospitalization.

Encourage deep breathing and coughing exercises.

Provide an eye shield to be worn while sleeping.

Teach a family member to administer eye drops.

Answer and Explanation

The Correct Answer is C

Choice A reason: Obtaining vital signs every 2 hours is standard postoperative care but does not specifically address the needs of a client recovering from retinal detachment surgery.

Choice B reason: While deep breathing and coughing exercises are important postoperative interventions, they are not specific to the care of a client after retinal detachment surgery.

Choice C reason: Providing an eye shield for sleep helps to protect the eye from accidental rubbing or pressure, which is critical after retinal surgery.

Choice D reason: Teaching a family member to administer eye drops is important for ongoing care but is not as immediately critical as protecting the eye from injury.

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Correct Answer is C

Explanation

Choice A reason: A thick, dry, and dark area on bilateral heels may indicate the beginning stages of a pressure ulcer, but it is not the earliest sign. The earliest indication is usually a non-blanchable redness over a bony prominence.

Choice B reason: Broken skin without evidence of undermining could be a sign of a pressure ulcer, but it is not the earliest indication. The earliest sign is persistent redness over an area of pressure.

Choice C reason: A defined area of persistent redness over bone, especially if it does not blanch when pressed, is the earliest indication of a pressure ulcer. This stage is known as a Stage 1 pressure injury.

Choice D reason: A superficial sacral ulcer with defined margins indicates that a pressure ulcer has already developed and is not the earliest sign of its development.

A. Measure body temperature. B. Assess skin turgor. C. Check for pedal edema. D. Observe the color of urine.

Correct Answer is D

Explanation

Choice A reason: Measuring body temperature is a standard procedure but not directly related to monitoring for adverse effects of prasugrel, which primarily include bleeding complications.

Choice B reason: Assessing skin turgor is generally used to evaluate hydration status and is not specific to prasugrel's adverse effects.

Choice C reason: Checking for pedal edema can indicate heart failure or vascular problems but is not a direct indicator of prasugrel's adverse effects.

Choice D reason: Observing the color of urine is important as prasugrel can cause significant and sometimes fatal bleeding. Dark or bloody urine may be an early indicator of such bleeding.

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For a client who has undergone surgery to repair a retinal detachment in the left eye, which intervention should the nurse implement during the postoperative period?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is confined to a wheelchair as a result of a motorcycle accident is unable to feel pain or pressure from the waist down. Which finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?

Correct Answer is C

Explanation

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care?

Correct Answer is D

Explanation

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For a client who has undergone surgery to repair a retinal detachment in the left eye, which intervention should the nurse implement during the postoperative period?