An adult client who was recently diagnosed with glaucoma tells the nurse, "It feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?
Avoid frequent eye pressure measurements.
Maintain prescribed eye drop regimen.
Wear prescription glasses.
Eat a diet high in carotene.
The Correct Answer is B
A. Avoiding frequent eye pressure measurements is not advisable; monitoring eye pressure is crucial in managing glaucoma.
B. Maintaining the prescribed eye drop regimen is the most important instruction because consistent use of these medications is critical to managing intraocular pressure and preventing vision loss associated with glaucoma.
C. While wearing prescription glasses can assist with vision, it does not address the underlying condition of glaucoma.
D. Eating a diet high in carotene is beneficial for overall eye health but does not directly impact the management of glaucoma. Regular use of prescribed eye drops is essential to prevent further damage to the optic nerve and potential blindness.
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Correct Answer is A
Explanation
A. The elevated heart rate and respirations suggest the client may be experiencing hypoxia, especially following a thoracotomy. Administering oxygen will help improve oxygen saturation levels and address potential respiratory distress.
B. While pain management is essential, the immediate concern is ensuring adequate oxygenation.
C. Administering IV fluids may be necessary but is secondary to ensuring the client's oxygenation.
D. Encouraging the client to splint and cough is important for preventing complications but does not address the immediate issue of vital signs indicating possible respiratory compromise.
Correct Answer is D
Explanation
A. While hematocrit levels provide information about blood volume status, they are not directly relevant to infection status or wound healing in burn patients.
B. Blood pH levels can indicate acid-base imbalances, but they do not specifically inform the nurse about the presence of infection.
C. Platelet count is important for assessing coagulation and bleeding risks, but it does not provide direct information regarding infection.
D. White blood cell (WBC) count is critical in assessing for infection, as an elevated WBC count can indicate the presence of an infection, particularly in a client with significant burns who is at increased risk for sepsis.