A nurse is assisting with the care of a client who is to receive a transfusion of packed red blood cells (RBCs). Which of the following actions should the nurse take? (Select all that apply)

Choice A reason: This is an incorrect action, because instructing the client to blink several times after instillation of the medication can cause the medication to drain out of the eye and reduce its effectiveness.

Choice B reason: This is a correct action, but not the best one. Asking the client to look straight ahead during instillation of the medication can help the nurse to aim the drop accurately and avoid touching the eye with the dropper.

Choice C reason: This is the best action, because applying pressure to the bridge of the nose after instillation of the medication can prevent the medication from entering the systemic circulation and causing adverse effects, such as bradycardia, hypotension, or bronchospasm.

Choice D reason: This is an incorrect action, because placing each drop of the medication directly on to the client's cornea can cause irritation, injury, or infection to the eye. The medication should be placed in the lower conjunctival sac of the eye.

Choice A reason: This is an incorrect finding, because ecchymosis of the thigh, or bruising, is not a sign of fat emboli, but a sign of bleeding or hematoma formation due to the fracture or the traction. The nurse should monitor the size and color of the ecchymosis and report any changes to the provider.

Choice B reason: This is an incorrect finding, because serous drainage at the pin site, or clear fluid, is not a sign of fat emboli, but a sign of normal healing or infection. The nurse should assess the amount, color, and odor of the drainage and report any signs of infection, such as purulent drainage, redness, swelling, or pain, to the provider.

Choice C reason: This is the correct finding, because chest petechiae, or small red spots on the chest, are a sign of fat emboli, which are a rare but serious complication of long bone fractures. Fat emboli occur when fat globules from the bone marrow enter the bloodstream and travel to the lungs, causing respiratory distress, hypoxia, and pulmonary edema. The nurse should report any signs of fat emboli, such as chest petechiae, dyspnea, tachypnea, tachycardia, fever, or confusion, to the provider.

Choice D reason: This is an incorrect finding, because muscle spasms in the left leg, or involuntary contractions of the muscles, are not a sign of fat emboli, but a sign of pain, inflammation, or nerve injury due to the fracture or the traction. The nurse should administer analgesics and muscle relaxants as prescribed, and provide comfort measures, such as massage, ice, or elevation, to the client.