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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

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.

Correct Answer is C

Explanation

Choice A rationale

Restricting fluids is not a primary limitation for clients with Crohn’s disease. Adequate hydration is important for overall health and managing symptoms.

Choice B rationale

Limiting foods high in calcium and iron is not typically recommended for Crohn’s disease. These nutrients are important for maintaining bone health and preventing anemia, which can be concerns for individuals with Crohn’s disease.

Choice C rationale

An elimination diet can help identify trigger foods that may exacerbate symptoms of Crohn’s disease. This approach involves removing certain foods from the diet and gradually reintroducing them to determine which foods cause symptoms.

Choice D rationale

Avoiding gluten is not necessary for all individuals with Crohn’s disease. While some may benefit from a gluten-free diet, it is not a universal recommendation for managing the condition.

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