The nurse is caring for a client who has undergone a cataract extraction and during the early postoperative period is complaining of nausea and severe eye pain over the operative site. What should be the initial nursing action?

Turn the client onto their operative side.

Administer the prescribed pain medication and antiemetic.

Call the surgeon.

Reassure the client that this is normal.

Answer and Explanation

The Correct Answer is B

A. Turning the client onto their operative side could increase pressure on the eye and is not an appropriate first action.
B. Administering prescribed pain medication and antiemetic is essential to address the client's severe pain and nausea, which are priority concerns in the postoperative period.
C. While it may be necessary to notify the surgeon if symptoms persist, the immediate priority is to alleviate the client's discomfort.
D. Reassuring the client that these symptoms are normal is misleading; severe pain and nausea postoperatively should be addressed promptly.

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Correct Answer is B

Explanation

A. Lowering the client's legs is not effective in managing autonomic dysreflexia and may not alleviate the cause of the high blood pressure.
B. Checking for a full bladder is the priority because bladder distension is a common trigger for autonomic dysreflexia in clients with spinal cord injuries, and relieving it can reduce the severe hypertensive response.
C. Antihypertensives may be used if non-pharmacological measures fail, but addressing the cause is the first action.
D. Pain medication is not indicated as the immediate intervention for autonomic dysreflexia, as the priority is identifying and removing the trigger.

A. Encourage fluid intake at and between meals. B. Cleanse the perineum from back to front. C. Offer the client the bedpan every 2 hours. D. Obtain a prescription for an indwelling urinary catheter.

Correct Answer is A

Explanation

A. Encouraging fluid intake at and between meals helps to dilute urine and can reduce the risk of urinary tract infections (UTIs) by promoting regular urination.
B. Cleansing the perineum should be done from front to back to prevent the introduction of bacteria from the rectal area to the urethra, so this option is incorrect.
C. Offering the bedpan every 2 hours may not be sufficient for individuals at risk for UTIs, as more frequent voiding can help prevent infection.
D. An indwelling urinary catheter increases the risk of urinary tract infections and should be avoided unless absolutely necessary; intermittent catheterization is generally preferred for those with spinal cord injuries to minimize this risk.

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The nurse is caring for a client who has undergone a cataract extraction and during the early postoperative period is complaining of nausea and severe eye pain over the operative site. What should be the initial nursing action?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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