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 D

Explanation

Choice A reason: Bright yellow

Bright yellow urine is typically a sign of normal hydration and is not expected after a transurethral prostatectomy. This color does not indicate the presence of blood or other substances that might be expected following surgery.

Choice B reason: Bright red

Bright red urine indicates significant bleeding, which is not typical after the initial postoperative period. While some blood in the urine is expected immediately after surgery, bright red urine should be reported to a healthcare provider as it may indicate a complication.

Choice C reason: Dark amber

Dark amber urine is usually a sign of dehydration or the presence of bilirubin. It is not typically associated with the expected postoperative changes following a transurethral prostatectomy. This color does not reflect the expected mild bleeding that can occur after the procedure.

Choice D reason: Pale pink

Pale pink urine is expected following a transurethral prostatectomy due to the presence of small amounts of blood in the urine. This is a normal finding as the surgical site heals. The pale pink color indicates mild bleeding, which is common and usually resolves as the healing process continues.

A. Apply a heat lamp twice a day. B. Reposition the client at least every 2 hours. C. Massage reddened areas with dressing changes. D. Clean the wound with hydrogen peroxide solution.

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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