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 ["400"]
Explanation
Step 1: Convert the volume of fluid to be infused from mL to L (since the rate is usually measured in mL/hr):
200 mL = 200 mL (No conversion needed as the volume is already in mL)
Step 2: Convert the time for infusion from minutes to hours (since the rate is usually measured in mL/hr):
30 minutes = 30 ÷ 60 = 0.5 hours
Step 3: Calculate the rate (volume ÷ time):
Rate = Volume ÷ Time
Rate = 200 mL ÷ 0.5 hours
Rate = 400 mL/hr
The nurse should program the infusion pump to deliver at a rate of 400 mL/hr.
Correct Answer is B
Explanation
Choice A reason: A blood pressure of 130/80 mm Hg is considered high normal and may not require immediate follow-up for a patient with a history of hypertension.
Choice B reason: A serum creatinine of 1.6 mg/dL is above the normal range for both males and females, indicating possible kidney dysfunction, which requires further follow-up.
Choice C reason: Dark yellow urine could be a sign of dehydration, which is common in diabetes, but it is not as concerning as an elevated serum creatinine level.
Choice D reason: Difficulty staying asleep could be related to various factors and may require follow-up, but it is not as urgent as abnormal laboratory values.
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