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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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Correct Answer is B

Explanation

Choice A rationale

An increase in B-lymphocytes and IgM is not how HIV suppresses the immune system. B-lymphocytes are responsible for producing antibodies, and IgM is a type of antibody. HIV primarily affects T-lymphocytes, specifically helper T-cells (CD4 cells), rather than B-lymphocytes.

Choice B rationale

The destruction of helper T-cells and CD4 cells is the primary mechanism by which HIV suppresses the immune system. HIV targets and infects these cells, leading to their depletion. Helper T-cells play a crucial role in coordinating the immune response, and their loss results in a weakened immune system, making the body more susceptible to infections and diseases.

Choice C rationale

A deficiency of cytotoxic T cells is not the primary mechanism by which HIV suppresses the immune system. Cytotoxic T cells (CD8 cells) are involved in directly killing infected cells, but the main impact of HIV is on helper T-cells (CD4 cells), which are essential for orchestrating the immune response.

Choice D rationale

The proliferation of suppressor T-cells is not how HIV suppresses the immune system. Suppressor T-cells (regulatory T cells) help regulate and control the immune response, but HIV primarily affects helper T-cells (CD4 cells), leading to their destruction and a weakened immune system.

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.

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