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

Explanation

Rationale:
A. Potassium 3.1 mEq/L (3.5 to 5 mEq/L): Hypokalemia increases the risk of digoxin toxicity because low potassium levels enhance digoxin’s effects on the myocardium, potentially leading to arrhythmias and other toxic effects. Monitoring electrolytes is crucial for clients taking digoxin, especially when on diuretics like furosemide.

B. WBC count 12,000/mm³ (5,000 to 10,000/mm³): An elevated WBC may indicate infection or inflammation but does not directly influence digoxin toxicity. This finding requires assessment but is not a risk factor for digoxin-related complications.

C. Fasting glucose 150 mg/dL (74 to 106 mg/dL): Elevated glucose reflects hyperglycemia but does not affect digoxin levels or toxicity risk. It should be managed separately according to the client’s metabolic needs.

D. Triglycerides 140 mg/dL (35 to 135 mg/dL): Mildly elevated triglycerides are a cardiovascular risk factor but do not directly increase the likelihood of digoxin toxicity. Lipid management is a separate consideration.

A. Discourage the client from allowing friends to see the newborn. B. Offer to take pictures of the newborn for the client. C. Assure the client that she can have additional children. D. Avoid talking to the client about the newborn.

Correct Answer is B

Explanation

Rationale:
A. Discourage the client from allowing friends to see the newborn: Restricting contact can hinder the grieving process. Allowing the client and close family or friends to see and hold the baby can help them acknowledge the loss, express emotions, and begin healthy mourning.

B. Offer to take pictures of the newborn for the client: Offering photographs provides the family with tangible memories that can support the grieving and healing process. Many parents later find comfort in having keepsakes, even if they initially decline them.

C. Assure the client that she can have additional children: Statements about future pregnancies minimize the client’s current grief and loss. The nurse should focus on supporting the client’s emotional needs in the present rather than redirecting attention.

D. Avoid talking to the client about the newborn: Avoiding discussion invalidates the client’s feelings and may intensify emotional isolation. Talking about the newborn by name, if known, acknowledges the baby’s existence and validates the parents’ grief, which is essential for emotional healing.

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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

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Explanation

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