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

Restrict head movement.

Remove eye patch in one month.

Apply cool compresses.

Eye drops to constrict the pupils will be prescribed.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Restricting head movement is a crucial preoperative instruction for a client scheduled for retinal detachment surgery. This helps to prevent further detachment and ensures that the retina remains in the best possible position for surgery. Keeping the head still minimizes the risk of additional damage and helps maintain the current state of the retina.

Choice B reason:

Removing an eye patch in one month is not a standard preoperative instruction. Eye patches are typically used postoperatively to protect the eye and aid in healing. The duration for wearing an eye patch varies depending on the specific case and the surgeon’s recommendations.

Choice C reason:

Applying cool compresses is not a typical preoperative instruction for retinal detachment surgery. Cool compresses are generally used to reduce swelling and discomfort postoperatively. Preoperative care focuses more on stabilizing the condition and preparing the client for surgery.

Choice D reason:

Eye drops to constrict the pupils are not commonly prescribed preoperatively for retinal detachment surgery. Instead, eye drops to dilate the pupils are often used to allow the surgeon a better view of the retina during the procedure. Pupil constriction is not typically necessary before surgery.

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Correct Answer is C

Explanation

Choice A reason: Aplastic anemia results in an increased rate of RBC destruction

Aplastic anemia does not result from an increased rate of red blood cell (RBC) destruction. Instead, it is characterized by the bone marrow’s inability to produce sufficient new blood cells, including RBCs, white blood cells, and platelets. This condition leads to pancytopenia, a deficiency of all types of blood cells.

Choice B reason: Aplastic anemia is associated with a decreased intake of iron

Aplastic anemia is not typically associated with a decreased intake of iron. Iron deficiency anemia is a different condition where the body lacks enough iron to produce hemoglobin. Aplastic anemia, on the other hand, is due to the failure of the bone marrow to produce adequate blood cells.

Choice C reason: Aplastic anemia results from decreased bone marrow production of RBCs

This statement is correct. Aplastic anemia occurs when the bone marrow fails to produce enough new blood cells. This can be due to various factors, including autoimmune disorders, exposure to toxic chemicals, certain medications, and viral infections. The decreased production of RBCs, along with other blood cells, leads to the symptoms associated with aplastic anemia.

Choice D reason: Aplastic anemia results in an inability to absorb vitamin B12

Aplastic anemia is not related to the absorption of vitamin B12. Pernicious anemia is the condition associated with an inability to absorb vitamin B12 due to a lack of intrinsic factor. Aplastic anemia is specifically related to the bone marrow’s failure to produce sufficient blood cells.

A. Ask the client to blow his nose. B. Suction the nostril. C. Notify the physician. D. Test the drainage for glucose.

Correct Answer is D

Explanation

Choice A reason: Ask the client to blow his nose

Asking the client to blow his nose is not advisable in this situation. Blowing the nose can increase intracranial pressure and potentially worsen the condition by causing more cerebrospinal fluid (CSF) to leak or even lead to further complications. Therefore, this action should be avoided.

Choice B reason: Suction the nostril

Suctioning the nostril is also not recommended. This action can introduce infection and increase the risk of further complications. It is important to handle any potential CSF leak with care to prevent infection and other issues.

Choice C reason: Notify the physician

While notifying the physician is important, it is not the immediate first step. The nurse should first confirm whether the clear drainage is CSF. Once confirmed, notifying the physician would be the next appropriate step.

Choice D reason: Test the drainage for glucose

Testing the drainage for glucose is the correct first action. CSF contains glucose, so a positive glucose test would confirm that the drainage is indeed CSF. This is a critical step in diagnosing a CSF leak, which can occur with basal skull fractures. Confirming the presence of CSF will guide further medical interventions and management.

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

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