A nurse is caring for a client who is comatose and requires a non-life-threatening surgical procedure. Which of the following actions should the nurse take?

A. "I should expect my tears to turn a red color after using the eye drops.": Timolol does not cause red discoloration of tears. Redness of the eye may indicate irritation, allergy, or another adverse effect, so the client should report persistent redness rather than expect it as normal.

B. "I will put pressure on the corner of my eye after using the eye drops.": Applying gentle pressure to the nasolacrimal duct (inner corner of the eye) after instilling timolol reduces systemic absorption and potential systemic side effects, such as bradycardia or hypotension. This technique demonstrates proper administration and understanding of safety precautions.

C. "The drops should be placed in the center of my eye.": Eye drops should be instilled into the lower conjunctival sac, not directly onto the center of the cornea, to reduce irritation and maximize absorption. Placing drops on the cornea can cause discomfort and reduce effectiveness.

D. "These drops will improve my cloudy vision.": Timolol lowers intraocular pressure but does not restore vision or improve cloudiness caused by glaucoma. The goal of therapy is to prevent progression of vision loss, not to reverse existing damage.

Rationale for correct choices

• Compartment syndrome: The adolescent demonstrates escalating pain despite repeated opioid administration, along with moderate edema, delayed capillary refill, and numbness/tingling in the affected limb. These signs indicate increased pressure within the casted compartment, which can compromise circulation and nerve function.

• Increasing capillary refill times: Capillary refill has lengthened from 3 to 4 seconds, suggesting impaired peripheral perfusion in the affected extremity. This change indicates vascular compromise and aligns with the pathophysiology of compartment syndrome. Monitoring these subtle vascular changes helps identify early ischemia before permanent damage occurs.

Rationale for incorrect choices

• Pneumonia: Shallow respirations and a slightly increased respiratory rate are present but are mild and likely related to pain or anxiety. Breath sounds remain clear, and oxygen saturation is slightly decreased but not critically low. There is no productive cough, fever spikes, or infection in the lungs, making pneumonia less likely.

• Infection: While the adolescent’s temperature has risen slightly, there is no redness, drainage, or local signs at the surgical site. White blood cell counts are not provided, and systemic signs of infection are minimal. The mild fever could be due to stress or inflammation from surgery rather than infection. Current symptoms points toward neurovascular compromise rather than infection.

• Shallow respirations: Although respirations are shallow at times, this finding alone is more consistent with pain or guarding from the femur injury than with a systemic complication. Respiratory assessment does not demonstrate adventitious sounds or significant hypoxia. Shallow breathing is not the primary indicator of compartment syndrome.

• Increasing respiratory rate: The rise in respiratory rate is minor and likely a response to pain, stress, or mild hypoxia, not the early sign of compartment syndrome. Tachypnea without other systemic signs does not reliably indicate limb vascular compromise. While important to monitor, it is not specific to the identified risk.