A nurse is planning care for a client 1 day postoperative following a detached retinal repair.
Which of the following instructions should the nurse include?

Allow the client to ambulate.

Remove the eye patch during the day.

Encourage coughing and deep-breathing.

Avoid reading and writing.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Allowing the client to ambulate one day after a detached retinal repair is not recommended. Ambulation can increase intraocular pressure and disrupt the healing process of the retina. The client should be advised to limit physical activity to prevent any strain on the eye.

Choice B rationale

Removing the eye patch during the day is not advisable as it can expose the eye to potential injury or infection. The eye patch helps protect the eye and maintain the correct position for healing. It should be worn as directed by the healthcare provider.

Choice C rationale

Encouraging coughing and deep-breathing exercises is not appropriate for a client who has undergone retinal repair. These activities can increase intraocular pressure and risk detachment of the retina. The client should avoid activities that cause strain or pressure on the eyes.

Choice D rationale

Avoiding reading and writing is crucial for a client one day postoperative following a detached retinal repair. These activities can cause rapid eye movements and strain, which can interfere with the healing process and reattachment of the retina. The client should be advised to rest their eyes and avoid any activities that require intense focus or eye movement.

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Correct Answer is A

Explanation

Choice A rationale

Administering the medications 5 minutes apart ensures that each medication has enough time to be absorbed without interference from the other. This practice helps to maximize the effectiveness of both medications and reduces the risk of adverse interactions.

Choice B rationale

Touching the tip of the dropper to the sclera of the eye can introduce contaminants and increase the risk of infection. It is important to avoid contact between the dropper and the eye to maintain sterility.

Choice C rationale

Holding pressure on the conjunctival sac for 2 minutes is not necessary for the administration of timolol and pilocarpine eye drops. This practice is more commonly recommended for other types of eye medications to increase absorption.

Choice D rationale

Contact lenses should be removed before administering eye drops to prevent contamination and ensure proper absorption of the medication. Wearing contact lenses during administration can interfere with the effectiveness of the drops.

A. Apply a non-pressure patch to the affected eye. B. Clean the eye from inner to outer canthus. C. Notify the surgeon. D. Instill an antibiotic solution in both eyes.

Correct Answer is C

Explanation

Choice A rationale

Applying a non-pressure patch to the affected eye can help protect the eye from further irritation or injury. However, it does not address the underlying issue of purulent drainage, which could indicate an infection that requires immediate medical attention.

Choice B rationale

Cleaning the eye from inner to outer canthus is a standard practice to prevent the spread of infection. However, in this case, the presence of purulent drainage suggests a possible infection that needs to be evaluated by a surgeon.

Choice C rationale

Notifying the surgeon is the priority action because purulent drainage from the eye can indicate a serious infection or complication following surgery. Immediate medical evaluation and intervention are necessary to prevent further complications and ensure proper treatment.

Choice D rationale

Instilling an antibiotic solution in both eyes may be part of the treatment plan for an infection. However, the nurse should first notify the surgeon to get appropriate orders and ensure that the correct antibiotic and treatment plan are followed.

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A nurse is planning care for a client 1 day postoperative following a detached retinal repair. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse is planning care for a client 1 day postoperative following a detached retinal repair.
Which of the following instructions should the nurse include?