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 D

Explanation

A. "Check the client's skin every 4 hr" is incorrect. Skin checks should be performed more frequently for clients who are immobilized, ideally every 2 hours, to detect early signs of pressure damage and prevent the development of pressure ulcers.

B. "Place a donut-shaped cushion under the client" is incorrect. Donut-shaped cushions can increase pressure on the surrounding tissue, leading to ischemia and an increased risk of pressure ulcers. They are not recommended for ulcer prevention.

C. "Turn the client every/hr" is incorrect. The client should be repositioned regularly, but turning the client every hour is not a standard practice. The typical guideline is every 2 hours for clients at risk of pressure ulcers.

D. "Place the client in a 30° lateral position" is correct. The 30° lateral position helps to reduce pressure on bony prominences, such as the sacrum and heels, and is effective in preventing pressure ulcers. This position minimizes pressure on the skin while promoting circulation.

A. "I am thankful I am done having children." B. "I should expect my periods to resume in 1 month." C. "I will have a large scar on my stomach after this procedure." D. "I will no longer need a regular gynecological examination."

Correct Answer is A

Explanation

A. "I am thankful I am done having children" is correct. This statement demonstrates the client's understanding of the procedure’s purpose, which is typically done to end the ability to conceive. The client is reflecting on a key aspect of the procedure, showing an informed decision about the surgery.

B. "I should expect my periods to resume in 1 month" is incorrect. A vaginal hysterectomy typically results in the permanent cessation of periods, so this statement indicates a lack of understanding of the procedure's effects.

C. "I will have a large scar on my stomach after this procedure" is incorrect. A vaginal hysterectomy is performed through the vaginal canal, and the client typically should not have a large abdominal scar. This statement may indicate a misunderstanding of the surgery's approach.

D. "I will no longer need a regular gynecological examination" is incorrect. While a vaginal hysterectomy removes the uterus, clients still need regular gynecological examinations, including Pap smears and other assessments, depending on their individual health needs. This statement reflects a misunderstanding of ongoing care requirements.

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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

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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