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Zorluk: OrtaBasic Care and Comfort

An older adult client is resting in bed following an uncomplicated right eye cataract extraction performed earlier in the day. The practical nurse is assisting the client with positioning for rest. Which action is most appropriate for the nurse to take?

  1. Elevate the head of the bed to 30 degrees and encourage the client to rest on the left side.Cevap
  2. B
    Position the client on the right side with a soft pillow placed under the head.
  3. C
    Place the client in a flat, supine position to ensure proper cervical alignment.
  4. D
    Apply soft wrist restraints to ensure the client does not inadvertently rub the operative eye.

Cevap

Elevating the head of the bed to 30 degrees and resting on the unoperated (left) side is the correct action to promote comfort and prevent increased intraocular pressure.
Following cataract extraction, it is critical to prevent an increase in intraocular pressure (IOP). Elevating the head of the bed to 30 degrees (Semi-Fowler's position) uses gravity to promote venous drainage from the head, effectively lowering IOP. Furthermore, placing the client on the unoperated side (the left side, in this case) ensures that no direct mechanical pressure is applied to the newly operated right eye, thus promoting both safety and basic comfort.

Adım Adım Çözüm

1
Identify the surgical procedure and the operative side.
The client had a right eye cataract extraction.
Knowing the operative side is essential to prevent placing direct pressure on the vulnerable surgical site.
2
Determine the physiological goals of basic post-cataract care.
The primary goal is to prevent any increase in intraocular pressure (IOP) while maintaining client comfort and protecting the eye from trauma.
Increased IOP can cause rupture of the delicate suture lines or result in intraocular hemorrhage.
3
Select the position that best achieves these physiological goals.
Semi-Fowler's position (head elevated 30 to 45 degrees) on the back or the non-operative (left) side is chosen.
Gravity helps drain fluid away from the eye when the head is elevated, and lying on the non-operative side prevents direct physical pressure on the right eye.

Anahtar Kavram

Post-procedure comfort and safety positioning to prevent increased intraocular pressure.
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Konular

Basic Care and Comfort

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