The practical nurse (PN) is reviewing a client's recent ophthalmic screening test results. Findings of optic neuropathy, loss of peripheral vision, and increased intraocular pressure are consistent with which medical condition?

The correct answer is choice C. Initiation of changes in infection control measures.

Choice A rationale:

Limiting the client’s fluid intake to avoid hemodilution is not relevant to managing a decreased ANC. Hemodilution is not a concern in this context, and fluid intake should generally be maintained to support overall health.

Choice B rationale:

Avoiding exposure to cold temperatures is not directly related to managing a decreased ANC. While keeping the client comfortable is important, it does not address the increased risk of infection associated with neutropenia.

Choice C rationale:

Initiation of changes in infection control measures is crucial when a client’s ANC decreases. Neutropenia increases the risk of infections, so enhanced infection control practices, such as strict hand hygiene, use of protective isolation, and monitoring for signs of infection, are essential to protect the client.

Choice D rationale:

Increasing the client’s dietary servings of fruits and vegetables is generally beneficial for overall health but does not specifically address the immediate risks associated with a decreased ANC. In fact, certain fresh fruits and vegetables might need to be avoided if they pose a risk of introducing pathogens.

The correct answers are Choice B and D:

Choice B: Report the appearance of the dressing to the charge nurse,

Choice D: Compress the drainage device before closing the tab.

Choice A rationale:

Documenting the appearance of the wound as inflamed is not appropriate. As a practical nurse, the immediate concern is to take action and report any concerning findings to the appropriate healthcare provider rather than just documenting it.

Choice B rationale:

Reporting the appearance of the dressing to the charge nurse is essential. The charge nurse or a more experienced healthcare provider needs to be informed of any abnormal findings or signs of infection for further evaluation and appropriate intervention.

Choice C rationale:

Removing the drainage device and applying a pressure dressing is not within the scope of practice for a practical nurse. These actions require a higher level of expertise and are typically performed by a registered nurse or healthcare provider.

Choice D rationale:

Compressing the drainage device before closing the tab is a correct action. This helps to ensure that the device is functioning properly, and there are no leaks or obstructions in the drainage system.

Choice E rationale:

Clamping the drainage tubing for the next four hours is not recommended unless specifically ordered by a healthcare provider. Clamping the drainage tubing without appropriate orders may disrupt the normal drainage process and cause complications.