A home health nurse is teaching an older adult client who just had cataract surgery. Which of the following instructions should the nurse include?
Rest in bed for at least 2 days.
Deep breathe and cough four times a day.
After two days, a creamy discharge is normal.
Keep your head up and straight.
The Correct Answer is D
Choice A reason: Resting in bed for at least 2 days is not necessary after cataract surgery. The client should resume normal activities as soon as possible, but avoid strenuous activities that increase intraocular pressure.
Choice B reason: Deep breathing and coughing four times a day are not related to cataract surgery. This is a technique to prevent respiratory complications after abdominal or thoracic surgery.
Choice C reason: After two days, a creamy discharge is not normal. This could indicate an infection or inflammation of the eye. The client should report any changes in vision, pain, redness, swelling, or discharge to the provider.
Choice D reason: Keeping the head up and straight is the correct instruction. This helps to prevent increased intraocular pressure and bleeding in the eye. The client should also avoid rubbing or touching the eye, wearing sunglasses to protect from bright light, and using prescribed eye drops as directed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: Obtaining the client's blood glucose every 12 hr is not enough, as the nurse should monitor it more frequently, at least every 4 to 6 hr, to prevent hyperglycemia or hypoglycemia. TPN is a high-glucose solution that can affect the blood sugar levels.
Choice B Reason: Changing the IV site dressing every 4 days is not enough, as the nurse should change it daily or as needed to prevent infection. TPN is a high-risk solution that can introduce microorganisms into the bloodstream.
Choice C Reason: This is the correct choice. Changing the IV tubing every 24 hr is recommended to prevent infection and maintain sterility. TPN is a complex solution that can support bacterial growth and contamination.
Choice D Reason: Weighing the client every other day is not enough, as the nurse should weigh the client daily to evaluate fluid balance and nutritional status. TPN can cause fluid retention or depletion, as well as weight gain or loss.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because this describes a stupor, which is a state of near-unconsciousness or reduced responsiveness. A stuporous client shows minimal movement and verbal responses and requires extreme vigorous stimulation such as painful stimuli to awaken briefly.
Choice B reason: This is incorrect because this describes obtundation, which is a state of reduced alertness or awareness. An obtunded client is extremely drowsy and minimally responsive and requires vigorous stimulation such as shaking or shouting to wake.
Choice C reason: This is incorrect because this describes lethargy, which is a state of decreased energy or activity. A lethargic client is alert and oriented x3 (to person, place, and time), but sluggish and drowsy, and wakes to voice or gentle shaking.
Choice D reason: This is incorrect because this describes a coma, which is a state of deep unconsciousness or unresponsiveness. A comatose client does not respond to verbal stimuli or speak and shows abnormal posturing in response to pain, such as decorticate (flexion of arms and extension of legs) or decerebrate (extension of arms and legs).
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