The nurse is providing care to a client having surgery to repair a retinal detachment to the left eye. Which intervention should the nurse implement during the postoperative period?
Obtain vital signs every 2 hours during hospitalization.
Provide an eye shield to be worn while sleeping.
Teach a family member to administer eye drops.
Encourage deep breathing and coughing exercises.
The Correct Answer is B
After retinal detachment surgery, it is crucial to protect the eye and the surgical repair site from accidental trauma or pressure. Providing an eye shield helps to shield the eye during sleep when the client may not have conscious control over their movements.
This can help prevent inadvertent rubbing or bumping of the eye, which could potentially disrupt the surgical repair and hinder the healing process.
Obtaining vital signs every 2 hours during hospitalization is a routine nursing intervention for postoperative care in general but is not specific to retinal detachment surgery. The frequency of vital sign monitoring may vary depending on the client's overall condition and the healthcare provider's orders.
Teaching a family member to administer eye drops may be necessary for the client's ongoing care, but it is not specifically related to the immediate postoperative period. Eye drop administration instructions can be provided as part of the client's discharge teaching.
Encouraging deep breathing and coughing exercises is a general postoperative intervention that promotes respiratory function and helps prevent complications such as pneumonia. While important for overall postoperative care, it is not specific to retinal detachment surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Assessing the client's level of consciousness involves observing their responsiveness, orientation, and ability to follow commands. If the client is unresponsive or exhibits any signs of altered consciousness, the nurse should immediately activate the emergency response system and begin resuscitative measures, such as administering oxygen and initiating cardiopulmonary resuscitation (CPR) if necessary.
Once the client's level of consciousness is established and the emergency response system has been activated if necessary, the nurse can proceed to assess the depth of the slashes, estimate the amount of blood loss, and find the object used to cause the injuries. These assessments will provide important information about the extent and severity of the client's injuries, which will guide subsequent interventions.
Correct Answer is D
Explanation
Itraconazole is an antifungal medication used to treat a variety of fungal infections. Antacids, which are used to treat heartburn and acid reflux, can decrease the absorption of itraconazole in the body. Therefore, it is important to instruct the client to avoid taking itraconazole with antacids. If the client needs to take an antacid, it should be taken at least 2 hours before or after taking itraconazole.
Reporting any difficulty with breathing is important as it can be a sign of an allergic reaction to the medication. Monitoring for changes in stool color is important as it can be an indication of liver dysfunction, which is a potential side effect of itraconazole.
Avoiding the consumption of grapefruit juice is important as it can increase the level of itraconazole in the body, which can increase the risk of side effects.
In summary, the client should be instructed to avoid taking itraconazole with antacids and to take any antacid at least 2 hours before or after taking itraconazole. The client should also be instructed to report any difficulty with breathing and to monitor for changes in stool color. Additionally, the client should avoid consuming grapefruit juice while taking itraconazole.
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