A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following instructions should the nurse include?
Apply cool compresses.
Eye drops to constrict the pupils will be prescribed.
Restrict head movement.
Keep both eyes patched.
The Correct Answer is C
Choice A rationale
Applying cool compresses can help reduce swelling and discomfort, but it is not the primary instruction for a client scheduled for retinal detachment surgery.
Choice B rationale
Eye drops to constrict the pupils are not typically prescribed for retinal detachment surgery. The focus is on preventing further detachment and ensuring proper healing.
Choice C rationale
Restricting head movement is crucial to prevent further detachment of the retina and to promote proper healing after surgery. The client should be instructed to avoid sudden or excessive head movements.
Choice D rationale
Keeping both eyes patched is not necessary and may cause unnecessary discomfort and disorientation for the client.
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Correct Answer is C
Explanation
Choice A rationale
Auscultating for wheezing is important but not the first action. The priority is to administer epinephrine to counteract the severe allergic reaction.
Choice B rationale
Assessing the client’s level of consciousness is important but not the first action. Administering epinephrine takes precedence to stabilize the client’s condition.
Choice C rationale
Administering epinephrine is the first action. It is crucial to counteract the severe allergic reaction and prevent further complications.
Choice D rationale
Monitoring for hypotension is important but not the first action. Administering epinephrine is the priority to stabilize the client’s condition.
Correct Answer is D
Explanation
Choice A rationale
Inactivated poliovirus (IPV) vaccine does not contain egg protein and is safe for individuals with egg allergies. There is no need to clarify this prescription.
Choice B rationale
Hepatitis B (HepB) vaccine does not contain egg protein and is safe for individuals with egg allergies. There is no need to clarify this prescription.
Choice C rationale
Haemophilus influenzae type b (Hib) vaccine does not contain egg protein and is safe for individuals with egg allergies. There is no need to clarify this prescription.
Choice D rationale
Influenza, live attenuated (LAIV) vaccine contains egg protein and can cause severe allergic reactions in individuals with egg allergies. This prescription should be clarified to ensure the safety of the child.