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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Radiation exposure to the eye is a serious condition that requires immediate medical attention. However, it is not a contraindication for ophthalmic ketorolac. In fact, ketorolac may be used to treat pain and inflammation associated with radiation exposure to the eye.
Ophthalmic ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that works by inhibiting the production of prostaglandins, which are substances that cause inflammation and pain.
Radiation exposure can damage the cells of the eye, leading to inflammation and pain. Ketorolac can help to reduce these symptoms.
However, it is important to note that ketorolac does not address the underlying cause of radiation exposure, and further treatment may be necessary.
Choice B rationale:
Corneal abrasion is a scratch on the surface of the cornea, the clear outer layer of the eye. It is a common eye injury that can be caused by a variety of factors, such as getting poked in the eye, rubbing the eye too hard, or wearing contact lenses for too long.
Ophthalmic ketorolac is contraindicated in patients with corneal abrasions because it can delay healing and increase the risk of infection.
This is because ketorolac inhibits the production of prostaglandins, which are involved in the healing process. Prostaglandins also play a role in fighting infection.
Therefore, using ketorolac in a patient with a corneal abrasion could potentially lead to a more serious infection.
Choice C rationale:
Chemical burn to the eye is a serious injury that requires immediate medical attention. Ophthalmic ketorolac is not typically used to treat chemical burns to the eye.
This is because ketorolac is not effective in reducing inflammation caused by chemical burns. In addition, ketorolac can potentially worsen the injury by delaying healing.
Choice D rationale:
Foreign body in the eye is a common eye injury that can be caused by a variety of objects, such as dust, sand, or metal shavings. Ophthalmic ketorolac is not typically used to treat foreign bodies in the eye.
This is because ketorolac will not help to remove the foreign body from the eye. In addition, ketorolac can potentially worsen the injury by delaying healing.
Correct Answer is B
Explanation
A Colloidal oatmeal-based lotion: Colloidal oatmeal can help to reduce itching and swelling, all while hydrating the skin. It is often used to soothe irritated skin and can be incorporated into a skincare routine through oatmeal baths or oatmeal-infused moisturizers. However, it is typically used as a complementary treatment and may not be sufficient to manage psoriasis symptoms on its own.
B Topical corticosteroids: These are an essential tool for treating inflammatory skin conditions such as psoriasis34. They work by reducing inflammation and slowing down the production of skin cells, which helps to alleviate symptoms such as redness, itching, and scaling. Topical corticosteroids are often the first line of treatment for mild to moderate psoriasis.
C. Topical analgesics: These are primarily used to relieve pain. While they may provide some relief from discomfort associated with psoriasis, they do not address the underlying inflammation and rapid skin cell production that characterize this condition.
D Topical antifungal: Antifungal agents are typically used to treat conditions like seborrheic dermatitis and scalp psoriasis, or in areas where psoriasis involves folds in the skin, where there is an increased potential for localized infection. However, they are not typically used as a primary treatment for psoriasis.
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