A client is recovering from the surgical removal of glass in the right eye.
Which intervention should the nurse implement immediately following the procedure?
Encourage deep breathing and coughing exercises.
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.
The Correct Answer is C
Choice A rationale:
Deep breathing and coughing exercises are not a priority intervention immediately following eye surgery. They are more commonly used to prevent postoperative pulmonary complications, such as pneumonia or atelectasis, in patients who have undergone general anesthesia or have respiratory conditions.
While deep breathing and coughing exercises can help promote circulation and prevent blood clots, they are not directly relevant to protecting the eye after surgery.
Engaging in deep breathing and coughing exercises too soon after eye surgery could potentially increase intraocular pressure, which could strain the healing eye and potentially lead to complications.
Choice B rationale:
Obtaining vital signs every 2 hours is a standard nursing intervention for monitoring a patient's overall condition, but it is not the most immediate priority following eye surgery.
Vital signs can provide important information about the patient's heart rate, blood pressure, respiratory rate, and temperature, but they do not directly address the protection of the surgically treated eye.
While monitoring vital signs is important, it does not specifically address the prevention of injury or complications to the eye itself.
Choice C rationale:
Providing an eye shield is the most crucial intervention to protect the eye immediately following surgery. The eye shield serves several important purposes:
Protection from accidental injury: It prevents the patient from accidentally rubbing or bumping the eye during sleep, which could cause further damage or disrupt the healing process.
Prevention of infection: It helps to keep the eye clean and free from debris, reducing the risk of infection. Reduction of swelling: It can help to minimize swelling and discomfort by applying gentle pressure to the eye area.
Promotion of healing: By creating a dark and protected environment, the eye shield can promote rest and healing of the tissues.
Choice D rationale:
Teaching a family member to administer eye drops is an important intervention for long-term care, but it is not the most immediate priority following surgery.
The patient may be able to administer eye drops independently, or a nurse may be responsible for administering them in the initial post-operative period.
Focusing on teaching family members about eye drop administration right after surgery could distract from more urgent priorities, such as protecting the eye with an eye shield.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Famotidine is a histamine-2 receptor antagonist (H2RA) that decreases gastric acid secretion. It is often used to treat conditions such as ulcers, gastroesophageal reflux disease (GERD), and heartburn.
Bismuth subsalicylate, metronidazole, tetracycline, and pantoprazole are all medications used in the treatment of H. pylori infection. However, these medications can interact with famotidine, potentially leading to decreased efficacy or increased side effects.
Therefore, it is important for the nurse to review the client's electronic medical record for any current or recent use of famotidine before administering the H. pylori treatment regimen. This will help to ensure the safety and effectiveness of the treatment.
Choice B rationale:
Loperamide is an antidiarrheal medication. It is not typically used in the treatment of H. pylori infection and is not known to interact with the medications used in this regimen.
Choice C rationale:
Aspirin is a salicylate medication that is often used to treat pain, fever, and inflammation. It can also be used to prevent blood clots. However, aspirin can interact with bismuth subsalicylate, potentially leading to increased risk of bleeding.
Therefore, it is important for the nurse to assess the client's risk of bleeding before administering the H. pylori treatment regimen if they are also taking aspirin.
Choice D rationale:
Ipratropium is a bronchodilator medication that is used to treat asthma and chronic obstructive pulmonary disease (COPD). It is not typically used in the treatment of H. pylori infection and is not known to interact with the medications used in this regimen.
Correct Answer is A
Explanation
Rationale for Choice A:
Pursed-lip breathing:
Creates back pressure in the airways, which helps to keep them open longer during exhalation.
Slows down the breathing rate, allowing for more complete exhalation and better emptying of the lungs. Prevents air trapping, which can worsen shortness of breath.
Promotes relaxation and reduces anxiety, which can also help to improve breathing.
Rationale for Choice B:
Side-lying position with knees bent:
May not be the most effective position for improving gas exchange in a client with emphysema. Could potentially restrict chest expansion and make breathing more difficult.
May not be comfortable for all clients.
Rationale for Choice C:
Increasing breathing rate:
Can lead to hyperventilation, which can worsen shortness of breath and anxiety. Can also cause fatigue and muscle exhaustion.
Rationale for Choice D:
Raising hands above the head:
Does not significantly expand the diaphragm or improve gas exchange. May actually make breathing more difficult for some clients.
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