A nurse is assisting with discharge teaching for a client who is postoperative following the repair of a detached retina. Which of the following instructions should the nurse include in the teaching?

"You can take a stool softener to prevent constipation."

"You can remove your eye patch during the day."

"You should bend from the waist to pick up objects."

"You can apply a warm, moist compress to your forehead to reduce pain."

Answer and Explanation

The Correct Answer is A

A. "You can take a stool softener to prevent constipation." is correct. After a retinal detachment repair, clients should avoid straining during bowel movements, as increased intracranial pressure could affect the healing eye. Taking a stool softener is a helpful preventive measure to avoid constipation.

B. "You can remove your eye patch during the day." is incorrect. The eye patch should typically be worn continuously to protect the eye and support healing. The surgeon's specific instructions should be followed regarding when the patch can be removed.

C. "You should bend from the waist to pick up objects." is incorrect. After retinal surgery, clients should avoid bending from the waist as this can increase intraocular pressure, potentially compromising the surgical repair. Instead, clients should use proper body mechanics and bend at the knees.

D. "You can apply a warm, moist compress to your forehead to reduce pain." is incorrect. Applying a warm compress to the forehead is not typically recommended following a retinal repair. Clients should follow the specific post-operative instructions from the surgeon, which may include cold compresses or other methods of managing discomfort.

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Correct Answer is C

Explanation

A. Tinnitus is not typically associated with the ingestion of tyramine-rich foods while on tranylcypromine.

B. Hyperglycemia is not a common adverse effect related to tyramine interaction with tranylcypromine.

C. Hypertension is correct. Ingesting tyramine-rich foods (such as aged cheese, cured meats, and fermented foods) while taking tranylcypromine, a monoamine oxidase inhibitor (MAOI), can cause a hypertensive crisis. Tyramine is normally broken down by monoamine oxidase (MAO), and inhibiting this enzyme with tranylcypromine can lead to a dangerous increase in blood pressure.

D. Hematuria is not a known adverse effect of tranylcypromine or the ingestion of tyramine-rich foods.

A. Wear sterile gloves when in contact with body fluids. B. Use alcohol-based cleanser when hands are visibly soiled. C. Wash hands with soap and water for 20 seconds. D. Artificial nails can be worn when performing direct client care.

Correct Answer is C

Explanation

A. "Wear sterile gloves when in contact with body fluids" is incorrect. While sterile gloves are necessary for sterile procedures, clean gloves are generally sufficient for contact with body fluids. The main focus of hand hygiene is on proper handwashing techniques.

B. "Use alcohol-based cleanser when hands are visibly soiled" is incorrect. Alcohol-based hand sanitizers should not be used when hands are visibly soiled, as they are less effective in removing dirt, grease, or organic material. Soap and water are needed for visibly soiled hands.

C. "Wash hands with soap and water for 20 seconds" is correct. The recommended duration for handwashing is 20 seconds, which is sufficient for removing pathogens effectively. This is standard practice for maintaining proper hand hygiene in healthcare settings.

D. "Artificial nails can be worn when performing direct client care" is incorrect. Artificial nails and chipped nail polish are contraindicated in healthcare settings because they can harbor bacteria and increase the risk of infection transmission.

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A nurse is assisting with discharge teaching for a client who is postoperative following the repair of a detached retina. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is taking tranylcypromine and reports ingestion of tyramine-rich foods. The nurse should monitor the client for which of the following findings as an adverse effect of this medication?

Correct Answer is C

Explanation

A nurse is assisting with staff education about hand hygiene. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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