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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Verify the medication three times with the medication administration record.": This is the best practice for ensuring the correct medication is administered. The nurse should verify the medication when removing it from storage, before preparing the medication, and at the bedside before giving it to the patient to ensure the right drug, dose, patient, time, and route.
B. "Administer time-critical medication 60 min before or after the scheduled time.": Time-critical medications should be administered within a specified window of 30 minutes before or after the scheduled time, not 60 minutes. Administering medication too early or late could compromise its effectiveness.
C. "Identify the client by using one identifier before giving the medication.": The correct approach is to use two identifiers (e.g., name and date of birth) to verify the client's identity, not just one. This reduces the risk of medication errors.
D. "Document medication administration prior to administering medication.": Documentation should occur after medication administration, not before, to ensure accurate recordkeeping of the event.
Correct Answer is B
Explanation
A. Preferred bath time is incorrect. While important for comfort and care planning, the preferred bath time is not critical information for change-of-shift report unless directly relevant to immediate care.
B. Time of last pain medication is correct. Information about the last dose of pain medication is essential to assess the client’s current pain level and determine if another dose is required. It also helps to plan for ongoing pain management and monitor for signs of over-medication or under-medication.
C. Steps required for dressing change is incorrect. While it is important to know the steps for dressing changes, this would typically be included in the written care instructions, not necessarily as part of the verbal change-of-shift report.
D. Admission vital signs is incorrect. Admission vital signs are not typically necessary for change-of-shift report unless there has been a significant change in the client’s condition since admission. It is more important to focus on current assessments and interventions.
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