A nurse is caring for a patient who is postoperative day 1 with an abdominal incision following a hysterectomy. The patient states she is experiencing severe pain. Her blood pressure is 150/80 and her heart rate is 109. Which of the following actions should the nurse do first?

Choice A rationale

The reported pulse rate of 92 beats per minute falls within the expected reference range for a healthy adult, which is typically between 60 and 100 beats per minute. Because this value is hemodynamically stable and normal, there is no immediate physiological indication that the nurse needs to re-measure it. The AP's finding is consistent with a resting state, and unless the patient is symptomatic or has a specific cardiac history, this measurement is accepted.

Choice B rationale

The respiratory rate of 18 breaths per minute is within the normal adult range of 12 to 20 breaths per minute. This finding indicates that the patient is likely ventilating adequately without acute distress. Since the value is not tachypneic or bradypneic, re-measurement is not a priority. The nurse should continue to observe the patient's work of breathing and oxygen saturation, but the reported rate itself does not necessitate an immediate verification by the licensed nurse.

Choice C rationale

The reported blood pressure of 98/58 mm Hg is considered low, as a typical normal reading is approximately 120/80 mm Hg. Hypotension, generally defined as a systolic pressure below 90 mm Hg or a significantly low diastolic pressure, requires professional verification to ensure patient safety and clinical accuracy. The nurse must assess for signs of decreased organ perfusion, such as dizziness or confusion, and confirm the reading before making interventions or notifying the provider about the status.

Choice D rationale

A temperature of 98.8 F is well within the normal afebrile range for an adult, which usually spans from 96.4 F to 99.1 F. Since this reading does not indicate a fever or hypothermia, there is no clinical reason to doubt the AP's measurement or to perform a repeat assessment. The patient’s thermoregulation appears intact, and the nurse can move on to addressing more concerning vital signs, such as the low blood pressure reported in the set.

Choice A rationale

This instruction is incorrect because chronic open angle glaucoma is typically asymptomatic and painless until significant optic nerve damage has occurred. Timolol is a nonselective beta-adrenergic blocker used to reduce intraocular pressure, not an analgesic for acute pain. Relying on pain as a trigger for administration would lead to inconsistent dosing, allowing intraocular pressure to rise and causing irreversible vision loss from progressive nerve fiber layer destruction.

Choice B rationale

This is the correct instruction because open angle glaucoma is a chronic, progressive condition that currently has no cure. Timolol works by decreasing the production of aqueous humor in the ciliary body. To maintain intraocular pressure within the normal range of 10 to 21 mmHg and prevent further damage to the optic nerve, the medication must be used consistently every day for the remainder of the client's life.

Choice C rationale

This instruction is medically inaccurate for the management of glaucoma. Tapering medications after 10 days is a common protocol for acute inflammatory conditions treated with steroids, but it is inappropriate for glaucoma therapy. Discontinuing or tapering timolol would result in a rebound increase in intraocular pressure, which poses a severe risk for accelerated blindness. This condition requires permanent, life-long daily maintenance rather than a short-term therapeutic course.

Choice D rationale

This statement is misleading because it implies that the medication can be stopped once a normal intraocular pressure of 10 to 21 mmHg is achieved. In glaucoma management, reaching a target pressure does not mean the underlying pathology is resolved. The pressure is only maintained at normal levels because of the pharmacological action of the eye drops. If the client stops using the medication, the intraocular pressure will inevitably rise again.