A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction should the nurse provide?

Choice A reason: Reviewing written and verbal instructions for a reduced sodium diet is not directly related to the management of primary open-angle glaucoma (POAG). While a healthy diet can contribute to overall well-being, dietary sodium does not have a significant impact on intraocular pressure or glaucoma management. Therefore, this intervention does not directly address the client's primary condition of POAG.

Choice B reason: Teaching strategies for aseptic administration of the eye drops is a critical intervention for clients with POAG. Proper administration of ophthalmic drops is essential to avoid contamination and infection. Aseptic techniques include washing hands before administering the drops, avoiding touching the dropper tip to any surface (including the eye), and ensuring that the dropper cap is replaced tightly after use. These measures help maintain the sterility of the medication and prevent complications such as eye infections, which can exacerbate the client's condition.

Choice C reason: Describing how the use of the eye drops will help improve peripheral vision is not entirely accurate in the context of POAG. The primary goal of ophthalmic drops for POAG is to lower intraocular pressure and prevent further damage to the optic nerve, thereby preserving the remaining vision. These drops do not typically improve peripheral vision that has already been lost. Educating the client with accurate information about the purpose and benefits of the drops helps set realistic expectations and encourages adherence to the treatment regimen.

Choice D reason: Teaching the client to apply pressure over the inner eye corner (punctal occlusion) after administering eye drops is an important intervention. Punctal occlusion helps prevent the medication from draining into the tear duct and being absorbed systemically. This technique increases the contact time of the medication with the eye, enhancing its effectiveness and reducing potential systemic side effects. Clients should be instructed to gently press the inner corner of the eye for a few minutes after instilling the drops to ensure maximum benefit.

Choice E reason: Explaining the need to continue eye drops for the rest of their life is essential for clients with POAG. Glaucoma is a chronic condition that requires lifelong management to control intraocular pressure and prevent progression of the disease. Discontinuing the medication can lead to elevated intraocular pressures and irreversible vision loss. Clients should understand the importance of adherence to their prescribed treatment regimen and the lifelong commitment to managing their condition to preserve their vision and quality of life.

Choice A reason: Ensuring the IV solution is infusing at the prescribed rate is important, but it is not the first action the nurse should take. The symptoms the client is exhibiting—low blood pressure, tachycardia, restlessness, and irritability—are indicative of potential hypovolemic shock, likely due to bleeding. Immediate assessment for bleeding is more critical.

Choice B reason: Notifying the healthcare provider of the findings is essential, but it should be done after assessing the client for signs of bleeding. The nurse needs to quickly identify the source of the client’s symptoms before contacting the healthcare provider to provide a complete and accurate report of the situation.

Choice C reason: Checking under the back for evidence of bleeding is the correct first action. The client's symptoms suggest they might be experiencing hypovolemic shock due to postoperative bleeding. Identifying whether there is visible bleeding can help determine the next steps in managing the client's condition and providing appropriate interventions.

Choice D reason: Listening to lung sounds is important in a comprehensive assessment but is not the priority in this scenario. The client's symptoms strongly indicate a potential bleeding issue, so checking for evidence of bleeding should come first to promptly address the most life-threatening concern.