The nurse is providing care to a client having surgery to repair a retinal detachment to the left eye. Which intervention should the nurse implement during the postoperative period?
Obtain vital signs every 2 hours during hospitalization.
Provide an eye shield to be worn while sleeping.
Teach a family member to administer eye drops.
Encourage deep breathing and coughing exercises.
The Correct Answer is B
After retinal detachment surgery, it is crucial to protect the eye and the surgical repair site from accidental trauma or pressure. Providing an eye shield helps to shield the eye during sleep when the client may not have conscious control over their movements.
This can help prevent inadvertent rubbing or bumping of the eye, which could potentially disrupt the surgical repair and hinder the healing process.
Obtaining vital signs every 2 hours during hospitalization is a routine nursing intervention for postoperative care in general but is not specific to retinal detachment surgery. The frequency of vital sign monitoring may vary depending on the client's overall condition and the healthcare provider's orders.
Teaching a family member to administer eye drops may be necessary for the client's ongoing care, but it is not specifically related to the immediate postoperative period. Eye drop administration instructions can be provided as part of the client's discharge teaching.
Encouraging deep breathing and coughing exercises is a general postoperative intervention that promotes respiratory function and helps prevent complications such as pneumonia. While important for overall postoperative care, it is not specific to retinal detachment surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The client's statement of feeling worthless most days and having no interest in activities she previously enjoyed indicates a potential risk for self-directed violence, including self-harm or suicidal ideation. These signs are significant and require immediate attention and intervention by the nurse.
Assessing and addressing the client's risk for self-directed violence is of utmost importance to ensure her safety and well-being. The nurse should initiate a thorough assessment of the client's mental health, including assessing for any suicidal ideation, intent, or plans. It is crucial to establish a supportive and non-judgmental environment for the client to express her feelings and concerns.
The nurse should collaborate with the healthcare team to develop an appropriate care plan that may involve interventions such as close observation, involving a mental health professional, implementing safety measures, and providing emotional support.
While addressing other nursing problems, such as anxiety, imbalanced nutrition, and chronic low self-esteem, is important, the immediate concern is the client's risk for self-directed violence due to her feelings of hopelessness.
Correct Answer is ["B","D","F"]
Explanation
As people age, the turnover of skin cells decreases, resulting in slower wound healing. This can prolong the healing process and increase the risk of complications.
The immune system's function, including T-cell function, tends to decline with age.
T-cells play a crucial role in the immune response and wound healing. Decreased T-cell function can impair the body's ability to fight infection and promote efficient healing.
With aging, there is a natural loss of subcutaneous fat, which can affect wound healing. Subcutaneous fat provides padding and protection to the underlying tissues, and its reduction can increase the risk of tissue damage and delays in healing.
Insulin resistance, pigmentation changes, and polypharmacy are not directly age-related factors that impact wound healing. Insulin resistance is a condition related to impaired glucose metabolism and can affect wound healing in individuals with diabetes or other metabolic disorders, but it is not necessarily an age-related factor. Pigmentation changes and polypharmacy (the use of multiple medications) may be associated with aging but do not directly affect the physiological processes involved in wound healing.
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