An older client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Provide an eye shield to be worn while sleeping. This intervention is essential following cataract extraction and lens implant surgery to protect the eye from accidental trauma during sleep. The eye shield ensures that the eye is shielded from inadvertent rubbing or pressure, which could compromise the surgical site and lead to complications. Option A) Teach a family member to administer eye drops is incorrect because while eye drops may be part of the postoperative care, ensuring protection during sleep with an eye shield takes precedence to prevent injury. Option B) Encourage deep breathing and coughing exercises is incorrect as this intervention is more relevant for respiratory conditions or surgeries that involve the chest, not for eye surgeries like cataract extraction. Option D) Obtain vital signs every 2 hours during hospitalization is incorrect as this is not a specific intervention related to eye surgery postoperative care. Monitoring vital signs is important in general patient care but is not directly related to protecting the eye after cataract surgery. In an educational context, it is crucial for nursing students to understand the specific postoperative care requirements for different surgical procedures. Emphasizing the rationale behind each intervention helps students develop critical thinking skills in prioritizing patient care and understanding the rationale for each nursing action in providing safe and effective postoperative care.

Correct Answer: D

Rationale: In this scenario, the correct answer is option D: Urine leaking around the meatus. This finding warrants immediate intervention by the nurse because it indicates a potential complication such as urinary leakage, which could lead to infection or disruption of the surgical site. Addressing this issue promptly is crucial to prevent further complications and ensure the client's recovery. Option A (True urinary output of 50ml/hr) is not the most concerning finding in this context. While monitoring urinary output is important postoperatively, a consistent output of 50ml/hr may not immediately indicate a critical issue. Option B (Lower abdominal tenderness) is a common postoperative finding and may be expected after a suprapubic prostatectomy. While it should be monitored, it does not require immediate intervention unless it is severe or accompanied by other concerning symptoms. Option C (Blood urine output with clots) is also a serious finding that should be addressed, but in this case, the presence of clots alone may not always warrant immediate intervention unless it is causing obstruction or significant bleeding. This scenario is crucial for nursing students to understand the immediate postoperative assessment of clients undergoing genitourinary surgeries. Recognizing and prioritizing critical assessment findings can help prevent complications and promote optimal patient outcomes in clinical practice.

Correct Answer: C

Rationale: The correct answer is C) Tea and hot chocolate. When a client is recovering from urinary tract calculi, especially if they were calcium oxalate stones, they should limit their intake of foods and drinks high in oxalates, such as tea and hot chocolate. Oxalates can contribute to the formation of these types of stones, so restricting them can help prevent recurrence. Option A, low-sodium soups, is not directly related to urinary tract calculi, so it is not the most appropriate choice. Option B, overall fluid intake, should not be limited as adequate hydration is important in preventing stone formation. Option D, citrus fruit juices, should not be restricted unless the client has a specific sensitivity to them. In an educational context, it is crucial for nurses to provide accurate and relevant dietary information to clients recovering from urinary tract calculi to help prevent recurrence and promote optimal health. Understanding the impact of specific foods and fluids on the formation of stones is essential in guiding dietary recommendations.

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to implement is to schedule an appointment for the client to see the healthcare provider (Option A). The increased erythema with purulent exudate at the site indicates a possible infection, which is a common complication of corticosteroid use. By scheduling an appointment for the client to see the healthcare provider, the nurse ensures that the client receives a proper evaluation and appropriate treatment for the infection. This is crucial in preventing the infection from worsening and potentially leading to serious complications. Option B, advising the client to apply more corticosteroid cream, is incorrect as it can further exacerbate the infection by suppressing the immune response and promoting bacterial growth. Option C, recommending the use of an antibiotic ointment, is also incorrect as systemic antibiotics may be needed and should be prescribed by a healthcare provider after a thorough evaluation. Option D, instructing the client to stop using the medication for 24 hours, is not appropriate as the client needs prompt medical attention for the infection. Educationally, this scenario highlights the importance of recognizing potential complications of medication use and the need for timely intervention by healthcare providers. It emphasizes the role of nurses in assessing, triaging, and advocating for clients' health and well-being. Nurses play a crucial role in patient education, monitoring for adverse effects, and facilitating timely access to appropriate healthcare interventions.

Correct Answer: A

Rationale: In this scenario, the correct action is to replace latex-containing devices in the operating room with alternate synthetic materials. This is crucial because the client has a known allergy to bananas, and individuals with latex allergies often have cross-reactivity with certain fruits like bananas due to shared allergenic proteins. Latex can be found in many medical devices, and exposure during surgery can lead to a severe allergic reaction in sensitive individuals. Option B, administering an antihistamine before surgery, is not the most appropriate action in this situation. While antihistamines can help manage allergic symptoms, preventing exposure to latex is the priority to avoid a potential life-threatening reaction. Option C, notifying the surgeon about the client's banana allergy, is important but does not directly address the risk of latex exposure in the operating room. It is essential for the surgical team to be aware of all allergies, but the nurse must also take immediate action to prevent latex exposure. Option D, preparing to administer an epinephrine injection during surgery, is a reactive measure and should not be the primary strategy. Preventing exposure to the allergen is key in managing allergies effectively. Educationally, this question highlights the importance of thorough assessment, patient safety, and knowledge of common allergens in healthcare settings. Understanding cross-reactivity between latex and certain fruits is crucial for nurses to provide safe care and prevent adverse events in allergic individuals.