Which of the ff. nursing interventions would have the highest priority in the plan of care for the postoperative eye patient?

Correct Answer: C

Rationale: In the postoperative period for an eye patient, sudden onset of acute pain can be indicative of a complication or an issue that needs immediate attention. Promptly reporting and addressing the pain is essential to prevent any further complications, such as infection, corneal abrasion, or increased intraocular pressure. This intervention takes priority over the other options listed as it involves the patient's immediate safety and well-being. It is crucial to follow postoperative protocols and report any unexpected or severe symptoms to ensure appropriate treatment and prevent any potential harm to the patient's eyesight.

Correct Answer: C

Rationale: Total parenteral nutrition (TPN) is a method of providing nutrition intravenously to individuals who are unable to obtain adequate nutrition through oral or enteral routes. The components of a TPN solution typically include dextrose (a source of carbohydrates for energy), amino acids (building blocks of proteins), electrolytes (such as sodium, potassium, and magnesium to maintain proper balance), vitamins, and trace elements (such as zinc and selenium). Trace minerals are essential for various metabolic functions in the body, and their inclusion in TPN solutions is crucial to prevent deficiencies. Therefore, trace minerals are likely to be present in TPN solutions, making them an essential component, unlike the other options provided in the question.

Correct Answer: D

Rationale: Compartment syndrome is a serious condition that results from increased pressure within a closed anatomical space (compartment), leading to decreased circulation to local neuromuscular structures. In the case of a casted elbow, if compartment syndrome is left untreated and persists for more than 24 hours, irreversible damage can occur. This is due to the compromised blood flow causing tissue ischemia, which can lead to permanent nerve and muscle damage. Therefore, it is crucial for healthcare providers to monitor for signs and symptoms of compartment syndrome and intervene promptly to prevent long-term complications.

Correct Answer: A

Rationale: Statement A is incorrect because hepatitis A is not caused by an RNA virus of the enterovirus family. Instead, hepatitis A is caused by the hepatitis A virus (HAV), which belongs to the Picornaviridae family. Hepatitis A is primarily spread through the fecal-oral route, usually through the ingestion of contaminated food or water. Additionally, hepatitis A can be transmitted through close personal contact and sexual contact. While hepatitis A occurs worldwide, it is more prevalent in areas with poor sanitation and overcrowding.

Correct Answer: A

Rationale: The patient's presentation of stepping on a sharp object and not noticing the injury until later is suggestive of peripheral neuropathy, a common complication of long-standing diabetes. Peripheral neuropathy can decrease sensation in the feet, making the patient more susceptible to injuries. In diabetes, high blood sugar levels can damage the nerves throughout the body, particularly those in the extremities. This can result in decreased sensation and poor wound healing, putting the patient at risk for injuries like stepping on a sharp object without feeling it. Therefore, the likely problem the patient has is neuropathy affecting her peripheral nerves.