A nurse at an ophthalmology clinic is providing teaching to a client who has open-angle glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the following instructions should the nurse provide?
Administer the medications 5 minutes apart.
Hold pressure on the conjunctival sac for 2 minutes following application of drops.
It is not necessary to remove contact lenses before administering medications.
Administer the medications by touching the tip of the dropper to the sclera of the eye.
The Correct Answer is A
Choice A: Administer the Medications 5 Minutes Apart
Administering the medications 5 minutes apart is crucial when using multiple eye drops. This practice ensures that each medication has enough time to be absorbed without being washed out by the subsequent drop. This is particularly important for medications like timolol and pilocarpine, which are used to manage intraocular pressure in glaucoma.
Choice B: Hold Pressure on the Conjunctival Sac for 2 Minutes Following Application of Drops
Holding pressure on the conjunctival sac (punctal occlusion) for 2 minutes after applying eye drops can help reduce systemic absorption and increase the local effect of the medication. However, this instruction is not as critical as the timing between administering different eye drops.
Choice C: It Is Not Necessary to Remove Contact Lenses Before Administering Medications
This statement is incorrect. Contact lenses should be removed before administering eye drops to prevent contamination and ensure proper absorption of the medication. The lenses can be reinserted after a sufficient amount of time has passed, usually around 15 minutes.
Choice D: Administer the Medications by Touching the Tip of the Dropper to the Sclera of the Eye
This statement is incorrect. The tip of the dropper should never touch the eye or any other surface to avoid contamination. The correct method is to hold the dropper above the eye and squeeze out the prescribed number of drops into the conjunctival sac.
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Correct Answer is A
Explanation
Choice A: Hemorrhage
Hemorrhage is a significant and immediate postoperative complication following a transurethral resection of the prostate (TURP). This procedure involves removing part of the prostate gland, which can lead to bleeding. Monitoring for signs of hemorrhage, such as a significant drop in blood pressure, increased heart rate, and visible blood in the urine, is crucial. Early detection and intervention are essential to manage bleeding and prevent severe complications. Hemorrhage can lead to hypovolemic shock if not addressed promptly, making it the priority complication to monitor for.
Choice B: Infection
Infection is a common postoperative complication, but it typically develops a few days after surgery rather than immediately. Signs of infection include fever, chills, and increased white blood cell count. While it is important to monitor for infection, it is not the immediate priority compared to hemorrhage. Preventive measures, such as maintaining sterile techniques and administering prophylactic antibiotics, can help reduce the risk of infection.
Choice C: Urinary retention
Urinary retention can occur after TURP due to swelling or blood clots obstructing the urethra. This condition can cause discomfort and increase the risk of bladder damage. Monitoring for urinary retention involves assessing the client’s ability to void and checking for bladder distention. While it is an important complication to monitor, it is not as immediately life-threatening as hemorrhage.
Choice D: Pain
Pain is a common postoperative symptom and should be managed effectively to ensure the client’s comfort and recovery. However, pain management is typically addressed through prescribed analgesics and is not considered a life-threatening complication. Monitoring for pain and providing appropriate pain relief are essential aspects of postoperative care, but they do not take precedence over monitoring for hemorrhage.
Correct Answer is D
Explanation
Choice A: Perform a Blind Finger Sweep
Performing a blind finger sweep is not recommended because it can push the foreign object further into the airway, making the obstruction worse. This method is only advised if the object is clearly visible and can be safely removed without causing further harm.
Choice B: Turn the Client to the Side
Turning the client to the side can be helpful in certain situations, such as when the client is unconscious or at risk of vomiting. However, in the case of a conscious client with a foreign body airway obstruction, this action does not directly address the obstruction and is not the first priority.
Choice C: Insert an Oral Airway
Inserting an oral airway is typically used to maintain an open airway in an unconscious patient who cannot maintain their own airway. For a conscious client with a foreign body obstruction, this action is not appropriate and could cause further complications.
Choice D: Administer the Abdominal Thrust Maneuver
Administering the abdominal thrust maneuver (also known as the Heimlich maneuver) is the recommended first action for a conscious client with a foreign body airway obstruction. This technique involves standing behind the client, placing a fist just above their navel, and delivering quick, upward thrusts to expel the foreign object. This method is effective in creating an artificial cough that can dislodge the obstruction.
