When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

Delegation involves assigning tasks to individuals who have the appropriate skills and competence to perform them safely and effectively. Inserting urinary catheters for uncomplicated clients is a task that can be delegated to a practical nurse. It is a common procedure within the scope of practice for a practical nurse, and it does not require the level of assessment and critical thinking involved in evaluating and updating plans of care or receiving a postoperative client and conducting an assessment.

Verifying the readiness of clients for discharge typically involves comprehensive assessments, coordination with other healthcare professionals, and decision-making regarding the appropriateness of discharge. This task is generally performed by registered nurses (RNs) or other members of the healthcare team with advanced training.

Evaluating and updating plans of care for clients is a responsibility that falls within the scope of practice of registered nurses. It requires a higher level of assessment, clinical judgment, and decision-making, which are typically beyond the scope of practice of a practical nurse.

Receiving a postoperative client and conducting the assessment involves comprehensive assessment skills and critical thinking, which are typically within the scope of practice of a registered nurse or an advanced practice nurse.

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.