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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While it's important to know if the client can lie prone, this is not the most critical piece of information prior to an intravenous pyelogram.
Choice B reason: Asking about a shellfish allergy is crucial because the contrast dye used in an intravenous pyelogram may contain iodine, which can cause an allergic reaction in individuals with shellfish allergies.
Choice C reason: Knowing the last time the client had a bowel movement is less critical than knowing about potential allergies to the contrast dye.
Choice D reason: While it's important to know about medication schedules, the risk of an allergic reaction to the contrast dye is a more immediate concern that could affect the safety of the procedure.
Correct Answer is B
Explanation
Choice A reason: Telling the charge nurse and refusing to administer the placebo could be seen as insubordination and does not address the ethical concerns associated with placebo use.
Choice B reason: Discussing ethical concerns with the healthcare provider is the most appropriate action as it addresses the potential breach of patient trust and informed consent associated with placebo use.
Choice C reason: Administering the placebo as prescribed without addressing the ethical implications could compromise the nurse's professional integrity and the patient's trust.
Choice D reason: Informing the client that a placebo was prescribed could undermine the treatment plan and the provider-patient relationship, potentially causing harm to the client.
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