A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?
Explanation & Rationale
Choice A reason: Encouraging deep breathing and coughing exercises is generally important postoperatively to prevent respiratory complications. However, it is not specific to eye surgery and does not address the immediate care needs following the removal of glass from the eye.Choice B reason: Obtaining vital signs every 2 hours during hospitalization is a standard postoperative procedure to monitor for complications. While important, it is not an intervention specific to eye surgery and does not directly address the protection and care of the operated eye.Choice C reason: Providing an eye shield to be worn while sleeping is a crucial intervention immediately following eye surgery. The eye shield protects the operated eye from accidental injury, rubbing, or pressure during sleep. This helps to prevent complications and promotes healing by keeping the eye safe from potential harm while the client is unaware.Choice D reason: Teaching a family member to administer eye drops is important for ongoing postoperative care. However, it is not the immediate priority following the surgery. The first step is to ensure the protection of the eye, which can be achieved by providing an eye shield. Teaching about eye drop administration can be done later as part of the discharge instructions.