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 D
Explanation
A) Incorrect - Skin redness might indicate irritation, but the initial focus should be on the client's sensation.
B) Incorrect - Decreasing the strength of the electrical signals might be premature if the sensation is normal.
C) Incorrect - The amount of gel coating on the electrodes might not be the primary issue if the client is feeling a tingling sensation.
D) Correct- A tingling sensation is normal and expected when using a TENS unit, and it does not indicate any harm or damage to the skin or nerves. However, the sensation should not be painful or unpleasant for the client, and the nurse should adjust the intensity of the electrical signals accordingly.
Correct Answer is ["A","B","D","F"]
Explanation
A) Cerebral edema: Brain injury or trauma can lead to swelling and increased intracranial pressure.
B) Correct- Near- drowning causes acute asphyxia because it prevents the person from breathing in oxygen and exhaling carbon dioxide. Asphyxia is a condition where the body is deprived of oxygen, which can lead to loss of consciousness, brain injury, or death.
C) Incorrect- Hypertension is not a common complication following near-drowning. The focus should be on potential brain injuries and respiratory distress.
D) Correct- Near-drowning can lead to aspiration of water or other substances, which can result in respiratory distress.
E) Incorrect- hyperthermia is not likely to occur in this case because the child was exposed to cold water.
F) Correct- Head trauma can lead to bleeding within the brain, such as a subdural hemorrhage.
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