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A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

A.

Obtain vital signs every 2 hours during hospitalization.

B.

Provide an eye shield to be worn while sleeping.

C.

Teach a family member to administer eye drops.

D.

Encourage deep breathing and coughing exercises.

Answer and Explanation

The Correct Answer is B

Choice A rationale

 

Obtaining vital signs every 2 hours is important for monitoring the patient’s overall condition, but it is not the immediate priority following the surgical removal of glass from the eye.

 

Choice B rationale

 

Providing an eye shield to be worn while sleeping is crucial to protect the eye from injury and promote healing after the surgical removal of glass. This intervention helps prevent accidental rubbing or pressure on the eye.

 

Choice C rationale

 

Teaching a family member to administer eye drops is important for ongoing care, but it is not the immediate priority following the procedure. The immediate focus should be on protecting the eye and ensuring proper healing.

 

Choice D rationale

 

Encouraging deep breathing and coughing exercises is important for preventing respiratory complications, but it is not directly related to the immediate care of the eye following the surgical removal of glass.


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View Related questions

Correct Answer is ["A","D"]

Explanation

Choice A rationale:

Enalapril is an ACE inhibitor used to manage hypertension. While it is generally safe, in the context of pneumonia, it can potentially cause complications such as hypotension, especially if the patient becomes septic or dehydrated. Additionally, ACE inhibitors can cause a persistent cough, which might be confused with or exacerbate the symptoms of pneumonia.

Choice B rationale:

Admitting the patient to the medical floor is appropriate given the diagnosis of pneumonia and the patient’s symptoms. Hospitalization allows for close monitoring and administration of necessary treatments.

Choice C rationale:

Sending blood for a complete blood count and electrolytes is standard practice to assess the patient’s overall health and identify any potential complications such as electrolyte imbalances or infection severity.

Choice D rationale:

Supplemental oxygen at 10 L/min via nasal cannula is quite high and typically not the first choice for pneumonia patients. High-flow oxygen therapy or non-invasive ventilation might be more appropriate if the patient requires such high levels of oxygen. Generally, nasal cannulas are used for lower flow rates (up to 6 L/min), and higher flow rates can cause discomfort and nasal dryness.

Choice E rationale:

Ibuprofen is commonly used to manage fever and pain in pneumonia patients. It helps reduce fever and alleviate discomfort, which can improve the patient’s overall condition.

Choice F rationale:

Continuous pulse oximetry is appropriate for monitoring the patient’s oxygen saturation levels, especially given the initial low oxygen saturation on room air.

Choice G rationale:

Vital signs every 4 hours is a standard practice for monitoring patients with pneumonia to detect any changes in their condition promptly.

Choice H rationale:

A chest X-ray is essential for diagnosing and assessing the extent of pneumonia. It helps in identifying the presence of infiltrates, consolidation, or other complications.

Correct Answer is A

Explanation

Choice A rationale

Isolating the client from others is the most important action to prevent the spread of COVID-19. This includes isolating the client from other clients, family, and healthcare workers not wearing proper PPE2.

Choice B rationale

Reporting the COVID-19 result to the local health department is important but not the immediate priority. Isolation takes precedence to prevent transmission.

Choice C rationale

Teaching the client to wear a mask, hand wash, and social distance is essential but secondary to immediate isolation.

Choice D rationale

Counseling family members to monitor for symptoms is important but not the immediate priority. Isolation of the client is the first step.

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