The practical nurse (PN) is assisting a client to the bathroom after a right cataract extraction. The client has an eye shield over the right eye. How should the PN assist the client during ambulation?

Place the client in front of the nurse while both walk to the bathroom.

Stand in front of the client and lead the client forward to the bathroom.

Walk on the client's left side while assisting the client to the bathroom.

Support the client on the right side while walking to the bathroom.

Answer and Explanation

The Correct Answer is C

A. Placing the client in front of the nurse can be disorienting and unsafe, especially since the client has limited vision with the eye shield. The PN should be in a position to provide guidance and support.
B. Standing in front of the client while leading them could be confusing for the client, as they might not see where they are going. The PN should be positioned where they can offer clear support and direction.
C. Walking on the client’s left side is the best approach as it ensures that the PN is on the side of the unaffected eye. This position allows the PN to guide and support the client while the shielded eye is protected from potential hazards.
D. Supporting the client on the right side could interfere with the eye shield and the healing process. The PN should assist from the left side to avoid disturbing the protected eye and to provide better guidance.

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Correct Answer is A

Explanation

A. Evisceration is the protrusion of internal organs, such as the bowel, through a wound that has reopened. The observation of bowel on the skin indicates this serious complication.
B. Hemorrhage refers to excessive bleeding, which would not typically involve the appearance of bowel on the skin.
C. Infection could cause wound complications but would not lead to the sudden appearance of bowel outside the body.
D. Dehiscence is the partial or complete separation of wound edges, but it does not involve the protrusion of internal organs. Evisceration is a more severe progression where internal organs are exposed.

A. Describe the procedure to the client using a step-by-step approach. B. Ask the client to describe the intensity of the pain being experienced. C. Encourage the client to reminisce about a favorite past family event. D. Explain the benefits of various alternative strategies in managing pain.

Correct Answer is C

Explanation

A. Describing the procedure in detail can increase anxiety or focus the client on the pain rather than distracting them from it.
B. Asking the client to describe the pain could heighten their awareness of it, which is counterproductive to the goal of distraction.
C. Encouraging the client to reminisce about a favorite past family event is a distraction technique that shifts the client's focus away from the pain, helping to manage discomfort during the procedure.
D. Explaining alternative pain management strategies is useful but not a distraction technique; it does not provide immediate relief or shift the client's focus during the procedure.

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The practical nurse (PN) is assisting a client to the bathroom after a right cataract extraction. The client has an eye shield over the right eye. How should the PN assist the client during ambulation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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