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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The statement “Normalcy begins to return to the community” describes the reconstruction phase of disaster response, not the heroic phase. During the reconstruction phase, efforts are focused on rebuilding and restoring the community to its pre-disaster state. This phase involves long-term recovery and the re-establishment of normalcy.
Choice B reason: The statement “Personnel are willing to work in dangerous conditions to provide assistance” accurately describes the heroic phase of disaster response. During this phase, there is an immediate and intense effort to save lives and prevent further harm. First responders, healthcare workers, and volunteers often work tirelessly and risk their own safety to provide urgent assistance and support to those affected by the disaster.
Choice C reason: The statement “Responders experience exhaustion due to extended relief efforts” pertains to the disillusionment phase of disaster response. In this phase, the initial adrenaline and motivation begin to wane, and responders may feel overwhelmed and fatigued by the prolonged demands of relief efforts. This phase can lead to burnout and a sense of frustration among responders.
Choice D reason: The statement “Survivors come together and share stories of survival” is characteristic of the honeymoon phase of disaster response. During this phase, there is a strong sense of community and solidarity among survivors. People come together to support each other, share their experiences, and find comfort in their shared resilience.
Correct Answer is B
Explanation
Choice A reason:
Applying a heat lamp twice a day is not recommended for treating stage 3 pressure ulcers. Heat lamps can cause burns and further damage to the already compromised skin. The primary goal in treating pressure ulcers is to reduce pressure, keep the area clean, and promote healing. Heat lamps do not contribute to these goals and can potentially worsen the condition.
Choice B reason:
Repositioning the client at least every 2 hours is a crucial intervention for managing stage 3 pressure ulcers. Frequent repositioning helps to alleviate pressure on the affected area, improving blood flow and preventing further tissue damage. This practice is essential in preventing the progression of pressure ulcers and promoting healing. It is one of the most effective strategies in pressure ulcer management.
Choice C reason:
Massaging reddened areas with dressing changes is not advisable. Massaging can cause additional trauma to the skin and underlying tissues, potentially worsening the ulcer. Instead, gentle handling and appropriate wound care techniques should be used to avoid further damage. Massaging can also disrupt the healing process and increase the risk of infection.
Choice D reason:
Cleaning the wound with hydrogen peroxide solution is not recommended for stage 3 pressure ulcers. Hydrogen peroxide can damage healthy tissue and delay the healing process. It is better to use saline or other wound cleaning solutions that are gentle and effective in removing debris without harming the tissue. Proper wound cleaning is essential to prevent infection and promote healing.
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