Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant?
Observe pupil response of the right eye.
Turn, cough, and deep breathe every 2 hours.
Sleep flat in a supine position.
Administer a stool softener.
The Correct Answer is D
D A stool softener can help prevent straining during bowel movements, which could increase intraocular pressure and potentially harm the surgical site. Additionally, the nurse should advise the client to avoid activities that could increase pressure in the eye, such as bending at the waist, lifting heavy objects, or engaging in strenuous activities for a certain period post-surgery.
A Monitoring for changes in pupillary sizes is not specific to this type of surgery.
B Turn, cough, and deep breathe every 2 hours: This instruction is more relevant for clients who have undergone surgery or are at risk of developing respiratory complications, such as pneumonia. It is not specifically related to cataract extraction with a lens implant.
C Clients are usually advised to sleep with the head elevated or to avoid lying on the operative side to minimize the risk of intraocular pressure changes and discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Hydromorphone is an opioid analgesic that can cause constipation as a side effect by slowing down gastrointestinal motility. Prolonged use of opioids, such as hydromorphone, increases the risk of developing opioid-induced constipation (OIC), which can lead to discomfort, bowel obstruction, and other complications if left untreated.
B. Edema is not typically associated with hydromorphone use, especially when administered for a short duration.
C. Hydromorphone administration is not typically associated with significant alterations in heart rate or rhythm, especially when administered at appropriate doses.
D. hydromorphone administration is not typically associated with alterations in blood glucose levels. Therefore, assessing capillary glucose levels may not be the most relevant assessment in this scenario.
Correct Answer is B
Explanation
B. pH 7.46, PCO2 55 mm Hg, HCO3 36 mEq/L, PO2 95 mm Hg
The pH is high (alkalotic).
The HCO3 level is elevated, indicating metabolic alkalosis.
The PCO2 is high (respiratory acidotic picture due to secondary response). This option matches the criteria for metabolic alkalosis.
A. pH 7.30, PCO2 20 mm Hg, HCO3 22 mEq/L, PO2 85 mm Hg
The pH is low (acidic), not alkalotic.
The HCO3 level is within the normal range.
The PCO2 is low, which could indicate respiratory alkalosis. This option does not match the criteria for metabolic alkalosis.
C. pH 7.49, PCO2 45 mm Hg, HCO3 32 mEq/L, PO2 90 mm Hg The pH is high (alkalotic).
The HCO3 level is elevated, indicating metabolic alkalosis. The PCO2 is within the normal range.
This option does not meet the criteria for metabolic alkalosis D pH 7.29, PCO2 35 mm Hg, HCO3 25 mEq/L, PO2 99 mm Hg
The pH is low (acidic), not alkalotic. The HCO3 level is low, not elevated. The PCO2 is within the normal range.
This option does not match the criteria for metabolic alkalosis.
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