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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
Rationale:
A. Wear a gown when providing care: A gown should always be worn when caring for a client with C. difficile to prevent contamination of the nurse’s clothing with infectious spores. This is part of contact precautions, which are essential to stop transmission via direct or indirect contact.
B. Wash hands with an alcohol-based cleaner: Alcohol-based sanitizers are ineffective against C. difficile spores. Handwashing with soap and water is required after client contact because mechanical friction is needed to remove spores from the skin.
C. Change gloves after contact with infectious material: Gloves must be changed immediately after contact with contaminated surfaces or body fluids to prevent cross-contamination.
D. Wear an N95 respirator when providing care: An N95 respirator is unnecessary for clients with C. difficile because the infection is transmitted by contact, not airborne routes. Standard and contact precautions are sufficient for infection control.
E. Remove the thermometer from the client's room for use on another client: Equipment used for a client with C. difficile should remain dedicated to that client. Sharing devices like thermometers risks spreading spores to other clients, so disposable or patient-specific equipment must be used.
Correct Answer is B
Explanation
Rationale:
A. Decreased serum uric acid: In preeclampsia, serum uric acid levels are elevated, not decreased, due to reduced renal clearance and tissue ischemia. Increased uric acid is often one of the earliest laboratory indicators of preeclampsia.
B. Increased protein in urine: Proteinuria is a key diagnostic feature of preeclampsia resulting from glomerular endothelial damage that increases permeability to proteins. The presence of protein in the urine reflects kidney involvement and helps distinguish preeclampsia from gestational hypertension.
C. Increased platelet count: Preeclampsia is typically associated with thrombocytopenia (low platelet count) due to platelet aggregation and consumption within damaged blood vessels. An increased platelet count would not be expected in this condition.
D. Decreased BUN: In preeclampsia, renal perfusion is reduced, leading to elevated BUN and creatinine levels. A decrease in BUN would indicate improved kidney function, which is inconsistent with the pathophysiology of preeclampsia.
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