A client with open-angle glaucoma is using pilocarpine ophthalmic solution, a miotic agent. Which action should the nurse at the eye clinic include in evaluating the effectiveness of the medication?

Use Snellen chart to assess visual acuity.

Check amount of drainage from each eye.

Palpate eyelids for decreased swelling.

Review eye pressure measurements.

Answer and Explanation

The Correct Answer is D

Choice A reason: Using a Snellen chart to assess visual acuity is not a direct measure of the effectiveness of pilocarpine, which is used to lower intraocular pressure by constricting the pupil and increasing aqueous humor outflow. Visual acuity may be affected by other factors, such as refractive errors, cataracts, or macular degeneration.

Choice B reason: Checking the amount of drainage from each eye is not a relevant action for evaluating the effectiveness of pilocarpine, which does not affect tear production or drainage. Excessive or abnormal eye drainage may indicate an infection, allergy, or injury.

Choice C reason: Palpating the eyelids for decreased swelling is not a useful action for evaluating the effectiveness of pilocarpine, which does not cause or reduce eyelid swelling. Eyelid swelling may be caused by inflammation, infection, allergy, or trauma.

Choice D reason: Reviewing eye pressure measurements is the correct action for evaluating the effectiveness of pilocarpine, which is used to lower intraocular pressure in patients with open-angle glaucoma. High intraocular pressure can damage the optic nerve and cause vision loss. Pilocarpine reduces intraocular pressure by constricting the pupil and increasing aqueous humor outflow.

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Free Nursing Study Resources

Correct Answer is []

Explanation

Body System: Respiratory

The correct choice is A

Choice A: Assess lung sounds This is the correct choice because the client may have developed an allergic reaction to vancomycin, which can cause bronchospasm and wheezing. Assessing lung sounds can help the nurse monitor the client’s respiratory status and intervene if needed.

Choice B: Provide a calm environment This is not the correct choice because providing a calm environment is not specific to the respiratory system. It may help the client feel more comfortable, but it does not address the potential respiratory complications of an allergic reaction.

Choice C: Pain medication This is not the correct choice because pain medication is not related to the respiratory system. The client did not report any pain, and pain medication may have adverse effects on the respiratory system, such as respiratory depression.

Choice D: Chest x-ray This is not the correct choice because a chest x-ray is not indicated for the client at this time. A chest x-ray is a diagnostic test that can show abnormalities in the lungs, such as pneumonia or pleural effusion. However, the client’s symptoms are more likely caused by an allergic reaction, which would not be visible on a chest x-ray.

Body System: Cardiovascular

The correct answer is A, B, and C. Here are the explanations for each choice:

Choice A: Monitor vital signs continuously. This is a correct and appropriate nursing intervention for the cardiovascular system. The client may have hypotension, tachycardia, or arrhythmias due to anaphylaxis or the effects of medications. Continuous monitoring can help detect any changes and guide interventions accordingly .

Choice B: Provide warmth. This is also a correct and appropriate nursing intervention for the cardiovascular system. The client may lose heat due to vasodilation, sweating, or exposure during the procedure. Providing warmth can help prevent hypothermia and shivering, which can increase oxygen demand and worsen cardiac function. Providing warmth can also improve comfort and reduce anxiety .

Choice C: Defibrillator at bedside. This is another correct and appropriate nursing intervention for the cardiovascular system. The client is at risk of cardiac arrest due to anaphylaxis, bradycardia, or pacemaker malfunction. Having a defibrillator at bedside can facilitate prompt resuscitation if needed.

Choice D: ECHO. This is an incorrect and inappropriate nursing intervention for the cardiovascular system. ECHO is a diagnostic test that uses ultrasound waves to create images of the heart and its structures. It can help evaluate the client’s cardiac function, valve function, and presence of any complications such as pericardial effusion or tamponade. However, this is not a priority intervention for the client who is experiencing an anaphylactic reaction and needs immediate treatment to stabilize her condition. ECHO can be done later after the client recovers from the acute episode.

Body System: Immunological

The correct answer is **A and D**.

- Choice A: Administer antihistamine. This is a correct and appropriate nursing intervention for the immunological system. The client is having an anaphylactic reaction to vancomycin, which is a type of hypersensitivity reaction mediated by IgE antibodies. Antihistamines, such as diphenhydramine, can block the effects of histamine, which is a major mediator of allergic inflammation and symptoms. Antihistamines can help reduce itching, hives, flushing, and bronchoconstriction¹².

- Choice B: IV fluids. This is an incorrect and inappropriate nursing intervention for the immunological system. IV fluids are not directly related to the immune response or the allergic reaction. IV fluids are mainly used to maintain hydration, electrolyte balance, and blood pressure. However, IV fluids may be indicated for the client as part of the cardiovascular or renal system interventions³.

- Choice C: Assess rash. This is an incorrect and inappropriate nursing intervention for the immunological system. Assessing rash is not a specific intervention for the immune response or the allergic reaction. Assessing rash is part of the general assessment of the client's skin condition, which may reflect other factors such as infection, inflammation, or drug toxicity. However, assessing rash may be helpful to monitor the severity and progression of the allergic reaction and the effectiveness of the treatment⁴.

- Choice D: Administer steroid. This is a correct and appropriate nursing intervention for the immunological system. The client is having an anaphylactic reaction to vancomycin, which is a type of hypersensitivity reaction mediated by IgE antibodies. Steroids, such as methylprednisolone, can suppress the immune system and reduce the production of inflammatory mediators, such as cytokines and prostaglandins. Steroids can help decrease swelling, inflammation, and tissue damage¹².

Correct Answer is []

Explanation

Potential Condition:Methemoglobinemia

Methemoglobinemia is a condition in which the hemoglobin in the blood is unable to bind oxygen effectively, resulting in tissue hypoxia. It can be caused by exposure to certain drugs or chemicals, such as nitrates, benzocaine, or dapsone. Some symptoms of methemoglobinemia include cyanosis, headache, fatigue, dyspnea, and tachycardia. In severe cases, it can lead to seizures, coma, and death.

Actions to Take:

Draw blood for a complete blood count
administer methylene blue

A complete blood count (CBC) can help diagnose methemoglobinemia by measuring the level of methemoglobin in the blood. A normal level is less than 1%, while a level above 15% can cause symptoms. A level above 30% can be life-threatening. Methylene blue is a medication that can reduce methemoglobin back to normal hemoglobin and restore oxygen delivery to the tissues. It is given intravenously at a dose of 1-2 mg/kg over 5 minutes.

Parameters to Monitor:

Methemoglobin level
heart rate and rhythm

The methemoglobin level is the most important parameter to monitor in methemoglobinemia, as it indicates the severity of the condition and the response to treatment. The goal is to lower the level below 10% or until symptoms resolve. The heart rate and rhythm are also important to monitor, as methemoglobinemia can cause tachycardia and dysrhythmias due to hypoxia and acidosis. The goal is to maintain a normal sinus rhythm and a heart rate within the normal range for the client’s age and condition.

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A client with open-angle glaucoma is using pilocarpine ophthalmic solution, a miotic agent. Which action should the nurse at the eye clinic include in evaluating the effectiveness of the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

Patient Data Exhibits Review H and P, and nurse’s note. Identify from the choices below which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Correct Answer is []

Explanation

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