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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A Preventing esophageal reflux is essential in managing symptoms associated with a direct hiatal hernia. Nursing interventions may include promoting proper positioning (elevating the head of the bed), encouraging smaller, more frequent meals, avoiding trigger foods, and administering medications as prescribed to reduce acid reflux.

B Promoting intestinal peristalsis may be beneficial in certain gastrointestinal conditions, such as constipation but it is not directly related to the management of a direct hiatal hernia.

C Promoting effective swallowing is important for overall swallowing function and preventing aspiration in some cases, it may not directly address the symptoms or complications associated with a direct hiatal hernia.

D Maintaining intact oral mucosa is important for oral health and preventing complications such as oral mucositis, but it is not directly related to the management of a direct hiatal hernia.

A. Raise hands above the head to expand the diaphragm. B. Increase breathing rate for a full 30 seconds. C. Draw air in through nose and exhale slowly through pursed lips. D. Lay down on each side with knees bent and breathe from abdomen.

Correct Answer is C

Explanation

C. This technique, known as pursed lip breathing, can help improve gas exchange by slowing down the respiratory rate, promoting more efficient exhalation, and reducing air trapping in the lungs.

A. While raising the hands above the head can help expand the chest and improve lung expansion to some extent, it may not be as effective as pursed lip breathing in improving gas exchange or alleviating dyspnea.

B. Increasing the breathing rate for a full 30 seconds may not be beneficial and could potentially worsen dyspnea, especially in individuals with emphysema or other respiratory conditions.

D. While changing positions and focusing on diaphragmatic breathing can be helpful techniques in managing dyspnea, lying down on each side with knees bent may not be practical for a client who is ambulatory and experiencing mild dyspnea after ambulation.

To assess the quality of an adult client's pain, which approach should the nurse use?

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Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?

Correct Answer is A

Explanation

The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?

Correct Answer is C

Explanation

An adult client with multiple sclerosis (MS) fell while walking to the bathroom. On transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

The nurse is caring for a client who is taking diclofenac for rheumatoid arthritis. During a clinic visit, the client appears pale and reports increasing fatigue. Which of the client's serum laboratory values is most important for the nurse to review?

The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer. The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety and a hoarse voice. Which nursing problem is the priority for this client?

A client with emphysema reports difficulty breathing and exhibits audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants Immediate intervention by the nurse?

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

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