A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?
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
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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Correct Answer is B
Explanation
Choice A rationale
Providing step-by-step verbal directions may not be effective for clients with Huntington’s disease due to their cognitive impairments, which can include forgetfulness, impaired judgment, and difficulty concentrating.
Choice B rationale
Escorting the client to the cafeteria is the best approach as it ensures the client reaches the destination safely. Clients with Huntington’s disease often have unsteady gait and involuntary movements, making it difficult for them to navigate independently.
Choice C rationale
Orienting the client to the color-coding system may not be effective due to the cognitive impairments associated with Huntington’s disease, such as difficulty concentrating and impaired judgment.
Choice D rationale
Using the hospital map to show the client where the cafeteria is located is not practical for clients with Huntington’s disease due to their cognitive impairments, which can include forgetfulness and difficulty concentrating.
Correct Answer is B
Explanation
Choice A rationale
Teaching anxiety reduction methods for feelings of suffocation is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice B rationale
Increasing the daily intake of oral fluids to liquefy secretions is the most important action for the nurse to instruct the client about self-care. This helps to thin the mucus, making it easier to expectorate and improving breathing.
Choice C rationale
Calling the clinic if undesirable side effects of medications occur is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice D rationale
Avoiding crowded enclosed areas to reduce pathogen exposure is important but not the most immediate action needed to address the client’s respiratory symptoms.