For a client who has undergone surgery to repair a retinal detachment in the left eye, which intervention should the nurse implement during the postoperative period?
Obtain vital signs every 2 hours during hospitalization.
Encourage deep breathing and coughing exercises.
Provide an eye shield to be worn while sleeping.
Teach a family member to administer eye drops.
The Correct Answer is C
Choice A reason: Obtaining vital signs every 2 hours is standard postoperative care but does not specifically address the needs of a client recovering from retinal detachment surgery.
Choice B reason: While deep breathing and coughing exercises are important postoperative interventions, they are not specific to the care of a client after retinal detachment surgery.
Choice C reason: Providing an eye shield for sleep helps to protect the eye from accidental rubbing or pressure, which is critical after retinal surgery.
Choice D reason: Teaching a family member to administer eye drops is important for ongoing care but is not as immediately critical as protecting the eye from injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Mild sedation is a common and expected side effect of ramelteon, which is a sedative used to treat insomnia. It is generally not a cause for concern unless it persists or worsens.
Choice B reason: Dizziness reported after the initial dose is also a common side effect of ramelteon. It usually diminishes as the body adjusts to the medication. However, if dizziness persists or is severe, it should be reported to the healthcare provider.
Choice C reason: Somnambulism, or sleepwalking, is a serious side effect that should be reported to the healthcare provider immediately. Ramelteon can cause people to engage in activities while not fully awake and have no memory of the activity afterward. This could include walking, driving, eating, or making phone calls, and poses a significant safety risk.
Choice D reason: A change in the sleep-wake cycle is an expected effect of ramelteon, as it is used to manage the sleep-wake cycle in people with insomnia. It is not typically a side effect that needs to be reported unless the changes are extreme or cause significant distress.
Correct Answer is B
Explanation
Choice A reason: While living in older housing projects can pose a risk, the age of the child and their behaviors, such as hand-to-mouth activities, make younger children more susceptible.
Choice B reason: A 2-year-old is at the highest risk due to their developmental stage, which includes frequent hand-to-mouth activity and the likelihood of playing in soil or dust that may be contaminated with lead.
Choice C reason: Adolescents working in a paint factory may be exposed to lead; however, they are less likely to engage in hand-to-mouth behaviors that lead to ingestion, which is the primary route of lead poisoning in children.
Choice D reason: A 10-year-old with Type 1 diabetes mellitus does not have an increased risk of lead poisoning based on their condition alone.
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