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.

Answer and Explanation

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.

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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.

A. The nurse will encourage the client to walk thirty minutes every day. B. The client will monitor blood glucose and blood pressure after each meal. C. The client's daily blood pressure will be less than 140/80 mm Hg this month. D. The client's blood pressure readings will be less than 160/90 mm Hg.

Correct Answer is C

Explanation

Choice A reason: Encouraging the client to walk thirty minutes every day is a good practice but does not directly relate to the immediate outcome of managing chest pain.

Choice B reason: Monitoring blood glucose and blood pressure is part of ongoing management but is not a specific outcome related to exertional chest pain.

Choice C reason: Maintaining a daily blood pressure of less than 140/80 mm Hg is a specific and measurable outcome that can help manage symptoms of cardiovascular disease and prevent complications.

Choice D reason: A blood pressure reading of less than 160/90 mm Hg is less stringent than current guidelines suggest for optimal control in cardiovascular disease.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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