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.
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Related Questions
Correct Answer is B
Explanation
Choice A reason:
Explaining the discharge instructions to the client and parents is important for ensuring they understand how to care for the cast and recognize signs of complications. However, this is not the immediate priority. The primary concern should be assessing the client’s current condition to ensure there are no immediate risks, such as compromised circulation or nerve damage.
Choice B reason:
Performing a neurovascular assessment is the priority action. This assessment involves checking for circulation, movement, and sensation in the affected limb. It is crucial to identify any signs of neurovascular compromise, such as decreased blood flow or nerve damage, which can occur with a new cast. Early detection of these issues can prevent serious complications.
Choice C reason:
Providing reassurance to the client and parents is important for their emotional well-being and can help reduce anxiety. However, it is not the immediate priority. Ensuring the physical health and safety of the client through a neurovascular assessment takes precedence.
Choice D reason:
Applying an ice pack to the casted leg can help reduce swelling and pain, but it is not the immediate priority. The first step should be to assess the neurovascular status to ensure there are no urgent issues that need to be addressed.
Correct Answer is ["31"]
Explanation
Step 1: Determine the total volume to be infused.
- Total volume = 250 mL
Step 2: Determine the total time for infusion in minutes.
- Total time = 2 hours
- Convert hours to minutes: 2 hours × 60 minutes/hour = 120 minutes
- Result: 120 minutes
Step 3: Determine the drop factor.
- Drop factor = 15 gtts/mL
Step 4: Calculate the flow rate in drops per minute.
- Flow rate (gtts/min) = (Total volume in mL × Drop factor) ÷ Total time in minutes
- Flow rate (gtts/min) = (250 mL × 15 gtts/mL) ÷ 120 minutes
- Result: (250 × 15) = 3750
- Result: 3750 ÷ 120 = 31.25
Step 5: Round the result to the nearest whole number.
- Rounded result: 31
Final Answer: The nurse should adjust the flow rate to deliver 31 drops per minute.
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