Priority Decision: To promote effective coughing, deep breathing, and ambulation in the postoperative patient, what is most important for the nurse to do?

Correct Answer: C

Rationale: In the postoperative period, promoting effective coughing, deep breathing, and ambulation are crucial to prevent complications such as pneumonia, atelectasis, and thromboembolism. The most important action for the nurse to take to support these activities is to provide adequate and regular pain medication (Option C). By managing the patient's pain effectively, the nurse can help alleviate discomfort, which in turn promotes better engagement in activities like coughing, deep breathing, and ambulation. Pain control is essential as uncontrolled pain can hinder a patient's willingness and ability to participate in these essential postoperative activities. Teaching the patient controlled breathing (Option A) and explaining the rationale for the activities (Option B) are important aspects of patient education but providing pain relief takes precedence in this scenario. Pain can be a significant barrier to a patient's willingness to engage in these activities, so addressing pain first is key. Using an incentive spirometer to motivate the patient (Option D) is a valuable intervention to improve lung function; however, it is not the most critical action in this situation. Without adequate pain control, the patient may not be able to effectively utilize the incentive spirometer due to discomfort. In an educational context, this question highlights the importance of prioritizing interventions based on patient needs. Pain management is a fundamental aspect of postoperative care that can significantly impact a patient's ability to participate in essential activities for recovery. Nurses must address pain effectively to optimize patient outcomes and promote successful postoperative recovery.

Correct Answer: D

Rationale: In the context of a hemiplegic patient, the correct initial goal for ambulation is the ability to transfer from bed to chair (Option D). This is because successful bed to chair transfers are crucial for promoting independence and mobility in hemiplegic patients. Mastering this skill enhances the patient's ability to perform activities of daily living and is a fundamental step towards eventual ambulation. Option A, acceptance of altered body image, is not the immediate priority for achieving ambulation. While addressing body image concerns is important for overall psychological well-being, it is not directly related to the physical ability to ambulate. Option B, balance training, is essential for safe ambulation, but before focusing on balance, the patient must first demonstrate the ability to transfer from bed to chair effectively. Without this foundational skill, balance training may not be as effective or safe. Option C, adequate energy level, is important for sustaining ambulation efforts, but it is not the initial step in the care plan. Energy levels can be addressed and improved once the patient has successfully mastered bed to chair transfers and is progressing towards ambulation. In an educational context, understanding the sequential and progressive nature of rehabilitation goals in hemiplegic patients is crucial for developing effective care plans. By prioritizing tasks based on their significance and impact on the patient's functional independence, healthcare professionals can optimize outcomes and promote successful rehabilitation.

Correct Answer: A

Rationale: The correct answer is A) permit drainage of aqueous humor from the anterior chamber. A peripheral iridectomy is a surgical procedure performed to create a small hole in the iris to allow for better drainage of aqueous humor in conditions like narrow-angle glaucoma. This procedure helps to relieve intraocular pressure and prevent further damage to the optic nerve. Option B) promoting the formation of permanent anterior synechiae with the cornea is incorrect because synechiae are adhesions between structures in the eye, which can lead to complications like angle-closure glaucoma, not the intended outcome of the procedure. Option C) promoting the formation of permanent posterior synechiae with the lens is also incorrect. Posterior synechiae are adhesions between the iris and the lens, which can lead to issues like posterior capsular opacification, not the goal of a peripheral iridectomy. Option D) gaining access to the lens for easy removal is not the purpose of a peripheral iridectomy. This procedure is specifically performed to address issues related to intraocular pressure and aqueous humor drainage, not for accessing or removing the lens. Understanding the purpose and implications of a peripheral iridectomy is crucial for nurses and healthcare professionals working with patients with glaucoma or other eye conditions requiring this procedure. It is essential to grasp the rationale behind each option to provide safe and effective care to patients undergoing such surgeries.

Correct Answer: A

Rationale: In this scenario, the most appropriate emergency treatment for Mr. Jones, who has a branch lodged in his eye with bleeding eyelid, is to cover the eye with a protective shield (Option A). This action helps to prevent further injury by providing a barrier that can stabilize the foreign object and protect the eye from additional trauma. Option B, encouraging Mr. Jones to hold his eye closed tightly, is incorrect as it may cause further damage by putting pressure on the foreign object. Option C, applying a pressure dressing to the eye, is also inappropriate as it can exacerbate the situation by increasing pressure on the lodged branch and causing more harm. Option D, removing the foreign body and applying a sterile dressing, is not recommended in this situation as removing the object without proper medical equipment and expertise can lead to more severe damage to the eye. Educationally, this question highlights the importance of understanding first aid principles in emergency situations involving eye injuries. It emphasizes the need to prioritize protecting the eye and seeking professional medical help promptly to prevent complications and ensure the best possible outcome for the patient.

Correct Answer: B

Rationale: The correct answer is B) She asks for medication upon the first indication of an attack. This option demonstrates that Mrs. Filbert understands the importance of early intervention in managing her condition effectively. By recognizing the signs of an impending attack and proactively seeking treatment, she shows comprehension of the teaching provided. Option A is incorrect because delaying medication out of fear of addiction is not a recommended approach in managing a medical condition. Option C is incorrect as it does not directly relate to understanding her condition. Option D is also incorrect as asking family for assistance at mealtime does not specifically indicate understanding of her medical condition. In an educational context, it is crucial for patients to demonstrate understanding of their condition by being proactive in managing their health. This includes recognizing symptoms, adhering to treatment plans, and seeking help when needed. By choosing option B, Mrs. Filbert displays a key aspect of patient education and empowerment in managing her health effectively.