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 D
Explanation
Choice A reason: Avoiding sunscreen is not recommended as it increases the risk of skin cancer; vitamin D can be obtained safely through diet and supplements.
Choice B reason: While it is true that vitamin D and calcium are balanced with phosphorus, this statement does not directly encourage compliance with supplementation.
Choice C reason: Although calcium uses vitamin D produced by sunlight exposure, relying solely on sunshine is not sufficient, especially for individuals at risk of osteoporosis.
Choice D reason: Emphasizing that vitamin D enhances calcium absorption into the bone provides a clear rationale for the client to comply with the supplementation regimen.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}
Explanation
Choice A Reason: Hypoglycemia refers to low blood sugar levels, typically below 70 mg/dL (3.9 mmol/L). The client’s fasting blood glucose level is 122 mg/dL (6.8 mmol/L), which is above the normal range, thus ruling out hypoglycemia.
Choice B Reason: Diabetes mellitus is diagnosed when the fasting blood glucose level is 126 mg/dL (7 mmol/L) or higher on two separate tests1. The client’s level is slightly below this threshold, suggesting that he does not currently have diabetes mellitus but is at risk.
Choice C Reason: Prediabetes is indicated by a fasting blood glucose level of 100 to 125 mg/dL (5.6 to 6.9 mmol/L)1. The client’s level falls within this range, indicating that he has higher than normal blood glucose levels but not high enough to be classified as diabetes, hence prediabetes.
Choice D Reason: Gestational diabetes occurs during pregnancy and is not applicable to this male client.
Option i Reason: Fatty liver disease is not directly indicated by the laboratory results provided and is typically associated with elevated liver enzymes and imaging findings.
Option ii Reason: Occupational factors are not directly related to the fasting blood glucose levels.
Option iii Reason: Lack of insulin production is a characteristic of type 1 diabetes, which is not indicated by the client’s fasting blood glucose level alone.
Option iv Reason: Impaired glucose tolerance is a condition where blood glucose levels are higher than normal but not high enough to be classified as diabetes. It is a characteristic of prediabetes and is indicated by the client’s fasting blood glucose level.
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