A nurse is receiving morning report when an alarm notifies the nurse that a client with chronic obstructive pulmonary disease (COPD) has an oxygen saturation of 89%. The nurse immediately assesses the client, and finds the client resting comfortably in bed on 2 liters of supplemental oxygen via nasal cannula. The client denies distress. Which of the following is the most appropriate nursing action?

A. Proper hand hygiene is critical to prevent introducing infections into the eye, especially after eye surgery. The client should always wash their hands before touching their eyes or administering any eye drops to maintain sterility and reduce the risk of infection.
B. After extracapsular cataract extraction, the cataract itself does not grow back on the implanted lens. However, a condition called posterior capsule opacification (PCO) can occur, where the membrane behind the lens becomes cloudy. This can be treated with a simple outpatient procedure called YAG laser capsulotomy.
C. Bending at the waist can increase intraocular pressure and put strain on the eye, which can hinder healing or increase the risk of complications. The client should be advised to avoid bending over and instead use alternative methods, such as bending their knees or getting assistance to reach items on the ground.
D. In modern cataract surgery, many procedures are performed without sutures or with self-sealing techniques that do not require suture removal. The specific follow-up care, including whether sutures need to be removed, should be confirmed with the surgeon.
E. Wearing an eye shield at night helps protect the eye from accidental rubbing or injury while sleeping, which is crucial for proper healing. The client should follow the physician's instructions regarding the duration of shield use, but wearing it until cleared by the physician is generally recommended to ensure the eye remains protected during the initial healing period.

Client's Response to Nitroglycerin Therapy

• Unstable Angina:
o Typically, unstable angina responds well to nitroglycerin. The relief of discomfort after nitroglycerin administration suggests that the chest pain was likely related to unstable angina, as it indicates a reduction in coronary artery spasm or temporary ischemia.
• Myocardial Infarction:
o In an MI, nitroglycerin may help alleviate pain, but it does not address the underlying cause of myocardial injury. The pain relief in an MI is generally more variable and may not be as effective if there is significant myocardial damage.

2. Client's Initial Report of Manifestations

• Unstable Angina:
o The symptoms described (shortness of breath, dizziness, and discomfort in the jaw, neck, and left arm) are consistent with unstable angina, which is characterized by episodes of chest pain or discomfort at rest or with minimal exertion, often associated with transient ischemia.
• Myocardial Infarction:
o These symptoms can also be consistent with MI, especially if they are severe or persistent. However, MI often presents with more intense and prolonged pain, and the discomfort might not always resolve with rest.

3. 12 Lead EKG Report

• Unstable Angina:
o ST depression on an EKG is more commonly associated with unstable angina, which indicates transient ischemia rather than a sustained myocardial injury.
• Myocardial Infarction:
o ST depression indicates ischemia commonly in angina.

4. Troponin Results

• Unstable Angina:
o Troponin levels are typically normal in unstable angina. The client’s troponin I (0.01 ng/mL) and troponin T (0.03 ng/mL) are within the normal range, suggesting no significant myocardial injury. This is consistent with unstable angina.
• Myocardial Infarction:
o Elevated troponin levels are a key marker of myocardial injury. The normal troponin results in this case do not support an MI diagnosis, as elevated troponin levels would be expected in MI.