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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 C

Explanation

Choice A rationale

Topical antifungals are used to treat fungal infections and are not effective for psoriasis, which is an autoimmune condition.

Choice B rationale

Colloidal oatmeal-based lotion can help soothe the skin but does not address the underlying inflammation and scaling associated with psoriasis.

Choice C rationale

Topical corticosteroids are the mainstay of treatment for psoriasis. They help reduce inflammation, itching, and redness associated with psoriatic plaques.

Choice D rationale

Topical analgesics can help relieve pain but do not address the underlying inflammation and scaling associated with psoriasis.

Correct Answer is A

Explanation

Choice A rationale

The severity of nausea and vomiting and serum amylase results are crucial in diagnosing and managing pancreatitis. Elevated serum amylase levels are a key indicator of pancreatitis, and the severity of nausea and vomiting can help assess the patient’s condition and response to treatment.

Choice B rationale

Reports of chronic constipation and serum gastrin levels are not directly related to the acute management of pancreatitis. Chronic constipation is more associated with gastrointestinal motility disorders, and serum gastrin levels are typically measured in conditions like Zollinger-Ellison syndrome.

Choice C rationale

Serum Helicobacter pylori (H. pylori) antibody results and urine output amounts are not directly relevant to the acute management of pancreatitis. H. pylori is associated with peptic ulcer disease, and urine output is more relevant in assessing renal function.

Choice D rationale

The presence of bowel sounds and the degree of abdominal pain are important but not as specific as serum amylase levels in diagnosing pancreatitis. Bowel sounds can be affected by various conditions, and abdominal pain is a common symptom in many gastrointestinal disorders.

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