A nurse is providing teaching to a client following surgery to repair a detached retina of the left eye. Which of the following instructions should the nurse include in the teaching?

"Take a stool softener daily."

"You can lift objects that weigh 15 pounds."

"Avoid reading for 3 days following surgery."

"Pick up items by bending at the waist."

Answer and Explanation

The Correct Answer is A

Rationale:
A. "Take a stool softener daily.": Preventing straining during bowel movements is critical after retinal surgery because increased intraocular pressure from straining can disrupt the surgical repair. Stool softeners help maintain soft stools and reduce the risk of increased eye pressure.

B. "You can lift objects that weigh 15 pounds.": Clients should avoid heavy lifting after retinal surgery to prevent increased intraocular pressure. The amount of weight considered safe is minimal, and lifting anything heavier can compromise the surgical site.

C. "Avoid reading for 3 days following surgery.": Light visual activities like reading are usually permitted after surgery, depending on provider instructions. Complete restriction is unnecessary, though clients should avoid activities that increase eye strain or involve prolonged downward gaze.

D. "Pick up items by bending at the waist.": Bending at the waist increases intraocular pressure, which can compromise the retina. Clients should be instructed to bend at the knees and keep the head upright when picking up objects to protect the surgical repair.

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Correct Answer is ["A","B","D"]

Explanation

Rationale:
A. "You sound like you have questions about your mom dying. Let's talk about it.": This response acknowledges the daughter’s emotional struggle and invites open dialogue. It encourages expression of thoughts and feelings, which supports coping and helps build trust.

B. "Tell me how you are feeling about your mom dying.": This therapeutic response promotes emotional expression and validates the daughter’s experience. It allows the nurse to assess the daughter’s understanding, provide reassurance, and offer emotional support.

C. "Hospice will take good care of your mom, so I wouldn't worry about that.": This response minimizes the daughter’s emotions and shuts down communication. It focuses on reassurance rather than addressing the underlying fear or uncertainty the daughter feels about her mother’s death.

D. "Let's talk about your mom's cancer and how things will progress from here.": Providing honest and compassionate information about disease progression helps the daughter prepare emotionally and practically. It also fosters understanding and reduces anxiety about the unknown aspects of dying.

E. "Tell her not to worry. She still has plenty of time left.": Offering false reassurance denies the reality of the situation and prevents the daughter from processing anticipatory grief. Such a response discourages open, honest communication between the client and family.

A. Obtain a 12-lead ECG for the client. B. Administer sublingual nitroglycerin to the client. C. Measure the client's vital signs. D. Have the client stop walking and sit down.

Correct Answer is D

Explanation

Rationale:
A. Obtain a 12-lead ECG for the client: An ECG is important to assess for myocardial ischemia or infarction, but it should be done after immediate measures are taken to reduce myocardial oxygen demand.

B. Administer sublingual nitroglycerin to the client: Nitroglycerin helps relieve chest pain by dilating coronary arteries, but it should be given only after the client is safely seated or resting to prevent hypotension or injury.

C. Measure the client's vital signs: Vital signs provide valuable baseline data, but addressing the client’s immediate safety and reducing cardiac workload takes priority.

D. Have the client stop walking and sit down: Stopping activity decreases oxygen demand on the heart and prevents worsening ischemia or collapse, making it the first and most critical action.

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A nurse is providing teaching to a client following surgery to repair a detached retina of the left eye. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has cancer and is being transferred to hospice care. The client's daughter tells the nurse, "I'm not sure what to say to my mom if she asks me about dying." Which of the following responses by the nurse is appropriate? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse is caring for a client who has angina and reports a feeling of heaviness in the chest while ambulating in the hall. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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