The nurse is preparing an older adult client for discharge following cataract extraction. Which instruction should be included in the discharge teaching?
Avoid straining at stool, bending, or lifting heavy objects.
Irrigate conjunctiva with ophthalmic saline prior to instilling antibiotic ointment.
Do not read without direct lighting for 6 weeks.
Limit exposure to sunlight during the first 2 weeks when the cornea is healing.
The Correct Answer is A
A. Avoid straining at stool, bending, or lifting heavy objects: These activities can increase intraocular pressure and disrupt healing of the surgical site after cataract extraction. The client should be taught to avoid anything that could strain the eye and risk complications like hemorrhage or wound dehiscence.
B. Irrigate conjunctiva with ophthalmic saline prior to instilling antibiotic ointment:
Routine irrigation is not required and may introduce additional risk. Clients are instructed on proper hand hygiene and drop instillation rather than conjunctival irrigation.
C. Do not read without direct lighting for 6 weeks: While good lighting helps reduce eye strain, reading in lower light does not delay healing after cataract surgery. This instruction is unnecessary and could limit the client’s ability to resume normal activities.
D. Limit exposure to sunlight during the first 2 weeks when the cornea is healing: Although bright light can be uncomfortable post-surgery, wearing sunglasses typically offers sufficient protection. There is no requirement to restrict sunlight exposure completely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E","F"]
Explanation
A. Check the temperature of the humidified oxygen attached to the ventilator: The client is intubated and receiving humidified oxygen. If the oxygen is cold, it can contribute to hypothermia. Ensuring that the humidified oxygen is at an appropriate temperature will help prevent further heat loss.
B. Instill warm fluids in the nasogastric tube: Instilling warm fluids via a nasogastric tube is not a standard or efficient method for core rewarming in a hypothermic trauma client. It introduces a risk of aspiration and is less effective than other core rewarming techniques.
C. Microwave a pack of gauze and distribute across the body: Microwaving a pack of gauze is not a safe or controlled method to warm the body. It could result in burns or uneven heat distribution, which could be harmful.
D. Place ice packs around the client's head: Ice packs are typically used to lower body temperature, not raise it. Applying ice packs would worsen the hypothermia and is inappropriate in this case.
E. Apply warm blankets: Warm blankets are a common and effective method to increase body temperature in hypothermic patients. This will help promote heat retention and stabilize the patient's body temperature.
F. Use a fluid warmer for intravenous fluids: Cold intravenous fluids can lower body temperature further. A fluid warmer ensures that fluids are administered at body temperature, helping to prevent hypothermia.
G. Administer intravenous fluids with a rapid infuser: While rapid fluid administration is important for hemodynamic stabilization in trauma patients, it does not directly address body temperature. Without a warmer, rapid infusers can contribute to further cooling.
H. Administer an antipyretic: Antipyretics are used to reduce fever, but there is no indication that the client has a fever. The concern here is hypothermia, not an elevated temperature, so antipyretics would not be appropriate in this situation.
Correct Answer is A
Explanation
A. "Risk for self-directed violence as evidenced by feelings of hopelessness": The client’s feelings of hopelessness, combined with significant weight loss and loss of interest in activities, suggest possible depression. Hopelessness is a key symptom of depression, which can increase the risk for self-harm or suicide.
B. "Chronic low self-esteem as evidenced by feelings of worthlessness": Feelings of worthlessness are part of the larger picture of the client’s depression. The priority is to address the immediate risk of harm, which takes precedence over chronic low self-esteem.
C. "Anxiety as evidenced by abdominal discomfort secondary to depression": While abdominal discomfort can be a symptom of depression, it is secondary to the more immediate concern of the client’s potential risk for self-directed violence.
D. "Imbalanced nutrition as evidenced by 25 lb (11 kg) weight loss in four months": The significant weight loss is concerning, but it is likely a result of the client’s depression. The focus should first be on addressing the client’s safety, followed by nutrition and weight restoration.
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