A home health nurse is conducting a safety assessment for a client with decreased vision due to glaucoma. Which of the following interventions should the nurse prioritize to ensure a safe home environment for the client? Select all that apply

Place throw rugs and carpets throughout the home to add comfort and warmth.

Ensure that all electrical cords and wires are secured against walls and out of walkways.

Install bright, overhead lighting in every room and hallway to improve visibility.

Encourage the client to use a walking stick or guide dog when moving around the home.

Label kitchen cabinets and drawers with large-print, high-contrast labels.

Answer and Explanation

Correct Answer : B,C,D,E

A. Place throw rugs and carpets throughout the home to add comfort and warmth: Throw rugs and carpets can increase the risk of falls, especially for clients with vision impairments. They should be avoided.

B. Ensure that all electrical cords and wires are secured against walls and out of walkways: Preventing tripping hazards is critical for a client with vision impairment.

C. Install bright, overhead lighting in every room and hallway to improve visibility: Adequate lighting is essential for clients with glaucoma to help them navigate safely.

D. Encourage the client to use a walking stick or guide dog when moving around the home: This enhances mobility and safety for clients with decreased vision by providing support and guidance.

E. Label kitchen cabinets and drawers with large-print, high-contrast labels: This helps the client identify items more easily and reduces the risk of injury or confusion.

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Correct Answer is A

Explanation

A. Respiratory rate 8/min: Morphine sulfate is an opioid that can depress respiratory function. A respiratory rate of 8/min is dangerously low and indicates opioid-induced respiratory depression, a serious adverse effect that requires immediate intervention.

B. SaO2 94%: A SaO2 of 94% is within the normal range for many clients and does not indicate an immediate issue.

C. Pain level of 6 on a scale from 0 to 10: This is an expected finding after morphine administration, as it typically reduces pain but may not eliminate it entirely.

D. Sleepy, but arousing when her name is called: Sedation is a common side effect of morphine, but the client being arousable when their name is called is not an alarming sign.

A. Determine the location of the pain. B. Reposition the client. C. Review the effects of the pain medication. D. Administer the medication

Correct Answer is A

Explanation

A. Determine the location of the pain. The nurse should first assess the client's pain, including its location, intensity, quality, and factors that alleviate or exacerbate it. This assessment is critical to determining the most appropriate intervention and evaluating the effectiveness of the treatment.

B. Reposition the client: Repositioning is a valid nursing intervention for managing pain caused by discomfort or poor positioning. However, it should not be the first action, as the nurse must first assess the pain to determine if repositioning alone is sufficient or if medication is necessary.

C. Review the effects of the pain medication: While reviewing the effects of the prescribed medication is important to ensure its appropriateness and safety, this step is part of preparation for medication administration. It is not the first action; assessment of the client's pain takes priority.

D. Administer the medication: Administering pain medication without assessing the client's pain is not appropriate. Pain management should be individualized, and assessment ensures that the prescribed medication is suitable for the client's current pain and condition.

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A home health nurse is conducting a safety assessment for a client with decreased vision due to glaucoma. Which of the following interventions should the nurse prioritize to ensure a safe home environment for the client? Select all that apply

Nursing Test Bank

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