A patient's data shows consolidation in the right middle and lower lobe, consistent with pneumonia.
What actions can the nurse take to assist the patient in improving their ventilation and oxygenation? Select all that apply.

Choice A rationale:

Deep breathing and coughing exercises are not a priority intervention immediately following eye surgery. They are more commonly used to prevent postoperative pulmonary complications, such as pneumonia or atelectasis, in patients who have undergone general anesthesia or have respiratory conditions.

While deep breathing and coughing exercises can help promote circulation and prevent blood clots, they are not directly relevant to protecting the eye after surgery.

Engaging in deep breathing and coughing exercises too soon after eye surgery could potentially increase intraocular pressure, which could strain the healing eye and potentially lead to complications.

Choice B rationale:

Obtaining vital signs every 2 hours is a standard nursing intervention for monitoring a patient's overall condition, but it is not the most immediate priority following eye surgery.

Vital signs can provide important information about the patient's heart rate, blood pressure, respiratory rate, and temperature, but they do not directly address the protection of the surgically treated eye.

While monitoring vital signs is important, it does not specifically address the prevention of injury or complications to the eye itself.

Choice C rationale:

Providing an eye shield is the most crucial intervention to protect the eye immediately following surgery. The eye shield serves several important purposes:

Protection from accidental injury: It prevents the patient from accidentally rubbing or bumping the eye during sleep, which could cause further damage or disrupt the healing process.

Prevention of infection: It helps to keep the eye clean and free from debris, reducing the risk of infection. Reduction of swelling: It can help to minimize swelling and discomfort by applying gentle pressure to the eye area.

Promotion of healing: By creating a dark and protected environment, the eye shield can promote rest and healing of the tissues.

Choice D rationale:

Teaching a family member to administer eye drops is an important intervention for long-term care, but it is not the most immediate priority following surgery.

The patient may be able to administer eye drops independently, or a nurse may be responsible for administering them in the initial post-operative period.

Focusing on teaching family members about eye drop administration right after surgery could distract from more urgent priorities, such as protecting the eye with an eye shield.

Choice A rationale:

While some individuals with Crohn's disease may find that avoiding gluten improves their symptoms, this is not a universal recommendation.

Gluten restriction is more often indicated for those with celiac disease or gluten sensitivity.

It's important to individualize dietary recommendations based on personal triggers and sensitivities.

Choice B rationale:

An elimination diet is a systematic approach to identifying foods that may trigger or worsen Crohn's disease symptoms.

It involves removing certain foods from the diet for a period of time, typically 2-4 weeks, and then gradually reintroducing them one at a time to observe any reactions.

This process can help individuals pinpoint specific foods that contribute to their symptoms and make informed dietary choices to manage their condition.

Choice C rationale:

There is no evidence to support a general restriction of calcium and iron in individuals with Crohn's disease.

In fact, these nutrients are essential for overall health and should be consumed in adequate amounts unless a specific deficiency or intolerance is identified.

Restriction of these nutrients could lead to nutritional deficiencies.

Choice D rationale:

Fluid restriction is not a primary dietary limitation for individuals with Crohn's disease.

Maintaining adequate hydration is crucial for overall health, especially during flares when fluid loss through diarrhea may be increased.

Restricting fluids could potentially lead to dehydration and electrolyte imbalances.