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.

Answer and Explanation

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.

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Correct Answer is ["B","C"]

Explanation

Choice B rationale:

Gravity Facilitates Drainage:

Positioning the patient strategically utilizes gravity to encourage the flow of fluids and secretions away from the surgical site. This aids in preventing fluid accumulation and potential infection.

Reduces Pressure on Surgical Site:

Certain positions can minimize pressure on the incision and internal organs, promoting healing and reducing discomfort.

This is particularly important for patients with comorbidities like hypertension and heart failure, as they may have impaired wound healing and be more susceptible to respiratory complications.

Enhances Respiratory Function:

Specific positions can improve lung expansion and ventilation, which is essential for patients with a history of heart failure or respiratory issues.

This helps prevent atelectasis (collapsed lung areas) and pneumonia, which are common postoperative risks.

Common Post-Cholecystectomy Positions:

Semi-Fowler's Position:

The head of the bed is elevated 30-45 degrees, with knees slightly bent.

This position eases breathing, reduces pressure on the incision, and promotes drainage of fluids. Right Side-Lying Position:

The patient lies on their right side with a pillow between their knees.

This position encourages drainage from the liver and gallbladder, aiding in bile flow. Left Side-Lying Position:

The patient lies on their left side with a pillow between their knees.

This position promotes drainage from the stomach and pancreas, assisting in digestion. Supine Position:

The patient lies flat on their back with a pillow under their knees.

This position may be used for short periods, but prolonged supine positioning can increase pressure on the incision and lungs. High Fowler's Position:

The head of the bed is elevated 60-90 degrees, with knees slightly bent.

This position is often used for patients with respiratory issues or difficulty breathing, as it improves lung expansion.

Choice C rationale:

Performing drainage immediately after meals aids in efficient removal of bile and gastric secretions, preventing complications such as:

Bile Reflux:

Delayed drainage can cause bile to back up into the stomach, leading to nausea, vomiting, and discomfort. Infection:

Accumulation of fluids in the surgical site can increase the risk of bacterial growth and infection. Pancreatitis:

In rare cases, delayed drainage can cause inflammation of the pancreas due to obstruction of the pancreatic duct.

I'll address the rationales for choices A and D in the following sections.

A. Provide suctioning so the patient does not have to cough. B. Position the patient with the head of the bed elevated. C. Encourage the patient to take breaks from the oxygen mask every few hours. D. Ask the patient to do quick, shallow breaths. E. Teach the patient to cough at least once an hour. F. Avoid treating fever with antipyretics. G. Assist the patient in ambulating safely.

Correct Answer is ["B","E","G"]

Explanation

B. Position the patient with the head of the bed elevated. Rationale:

Promotes lung expansion: Elevating the head of the bed by at least 30 degrees utilizes gravity to assist in diaphragmatic descent and lung expansion. This allows for greater intake of air, optimizing oxygen intake and facilitating better gas exchange.

Reduces work of breathing: When upright, the abdominal muscles can more effectively aid in breathing, reducing the workload on the diaphragm and accessory muscles. This conserves energy and decreases the patient's respiratory effort.

Enhances secretion drainage: Gravity also aids in the movement of secretions from the lower lobes of the lungs towards the upper airways, where they can be more easily coughed up or suctioned. This helps to clear the airways and improve ventilation.

E. Teach the patient to cough at least once an hour. Rationale:

Clears secretions: Coughing is a natural mechanism to clear secretions from the lungs and airways. It helps to prevent mucus buildup and potential obstruction, which can lead to atelectasis (collapse of lung tissue) and further compromise ventilation.

Improves gas exchange: By removing secretions, coughing allows for better airflow and gas exchange within the lungs. This enhances oxygenation and helps to prevent respiratory complications.

G. Assist the patient in ambulating safely. Rationale:

Mobilizes secretions: Ambulation encourages movement of secretions from the lower lobes of the lungs, promoting their clearance and preventing mucus buildup.

Prevents atelectasis: Walking and movement help to expand the lungs, reducing the risk of atelectasis and improving overall ventilation.

Enhances circulation: Ambulation also improves circulation, which can help to deliver oxygen to the tissues more effectively and aid in healing.

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A client is recovering from the surgical removal of glass in the right eye.Which intervention should the nurse implement immediately following the procedure?

Nursing Test Bank

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A client is recovering from the surgical removal of glass in the right eye.
Which intervention should the nurse implement immediately following the procedure?