A nurse is caring for a client who has bilateral eye patches in place following an injury.
When the client’s food tray arrives, which of the following interventions should the nurse take to promote independence in eating?

Ask the client if she would prefer a liquid diet.

Assign an assistive personnel to feed the client.

Explain to the client that her tray is here and place her hands on it.

Describe to the client the location of the food on the tray.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Asking the client if she would prefer a liquid diet does not promote independence in eating. It may limit the client’s dietary options and does not address the need for the client to learn how to eat independently with bilateral eye patches.

Choice B rationale

Assigning an assistive personnel to feed the client does not promote independence. It makes the client reliant on others for feeding, which does not help in developing self-feeding skills.

Choice C rationale

Explaining to the client that her tray is here and placing her hands on it is a step towards promoting independence. However, it does not provide enough information for the client to locate and identify the food items on the tray independently.

Choice D rationale

Describing to the client the location of the food on the tray promotes independence by enabling the client to use her sense of touch and memory to locate and consume the food items without assistance.

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Correct Answer is C

Explanation

Choice A rationale

Applying cool compresses can help reduce swelling and discomfort, but it is not the primary instruction for a client scheduled for retinal detachment surgery.

Choice B rationale

Eye drops to constrict the pupils are not typically prescribed for retinal detachment surgery. The focus is on preventing further detachment and ensuring proper healing.

Choice C rationale

Restricting head movement is crucial to prevent further detachment of the retina and to promote proper healing after surgery. The client should be instructed to avoid sudden or excessive head movements.

Choice D rationale

Keeping both eyes patched is not necessary and may cause unnecessary discomfort and disorientation for the client.

A. The client had an allergic reaction to the ordered meperidine. B. The primary health care provider was notified because the client developed a rash after receiving an opioid analgesic. C. The client’s skin was warm and flushed, and a rash was noted on the chest and back. D. Thirty minutes after receiving meperidine, the temperature was 101°F (38.3°C).

Correct Answer is D

Explanation

Choice A rationale

Stating that the client had an allergic reaction to the ordered meperidine is not objective and does not provide specific details about the client’s condition.

Choice B rationale

Notifying the primary health care provider because the client developed a rash after receiving an opioid analgesic is important, but it does not include all the necessary details about the client’s condition.

Choice C rationale

Documenting that the client’s skin was warm and flushed, and a rash was noted on the chest and back is important, but it does not include the timing of the reaction or the client’s temperature.

Choice D rationale

Documenting that thirty minutes after receiving meperidine, the temperature was 101°F (38.3°C), the client’s skin was warm and flushed, and a rash was noted on the chest and back provides a complete and objective account of the client’s condition and the timing of the reaction.

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A nurse is caring for a client who has bilateral eye patches in place following an injury. When the client’s food tray arrives, which of the following interventions should the nurse take to promote independence in eating?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

Thirty minutes after receiving meperidine, the client develops a temperature of 101°F and the skin is warm and flushed with a notable rash on the chest and back. The nurse contacts the primary health care provider and begins to document on an incident report. Which information should be included?

Correct Answer is D

Explanation

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A nurse is caring for a client who has bilateral eye patches in place following an injury.
When the client’s food tray arrives, which of the following interventions should the nurse take to promote independence in eating?