A home health nurse is planning care for an older adult client who has vision loss and takes medications throughout the day.
Which of the following actions should the nurse include in the plan?

Cover appliance cords with throw rugs.

Visit the client once per month to assess medication usage.

Use container lids of different shapes to indicate times of administration.

Rearrange furniture to clear walkways.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Covering appliance cords with throw rugs is not an appropriate action to address the needs of a client with vision loss and medication management. While it promotes safety by reducing tripping hazards, it does not directly address the client's medication administration needs. Implementing measures that specifically assist the client in managing medications safely is essential in this scenario.

Choice B rationale:

Visiting the client once per month to assess medication usage is insufficient for an older adult with vision loss who takes medications throughout the day. Regular and more frequent assessments are necessary to ensure the client's safety and adherence to the medication regimen. The nurse should consider more proactive measures to support the client, such as providing medication organizers or arranging for a home healthcare aide to assist with medication administration daily.

Choice C rationale:

This is the correct answer. Using container lids of different shapes to indicate times of administration is an effective strategy for clients with vision loss. Associating specific shapes with different times of the day helps the client differentiate between medications, promoting accurate dosing. This method is tactile and easy for the client to understand, enhancing their ability to manage medications independently and safely.

Choice D rationale:

Rearranging furniture to clear walkways is a general safety measure but does not specifically address the client's medication administration needs. While it can prevent falls and accidents, it does not facilitate the client's ability to distinguish between different medications or their dosing schedules. The focus should be on implementing strategies that directly support the client in managing their medications effectively despite their visual impairment.

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Correct Answer is D

Explanation

A. Incorrect. Avoiding the issue by scheduling the nurses to have fewer shifts together might not address the underlying conflict and could lead to resentment.

B. Incorrect. To auscultate blood pressure accurately, it's essential to follow proper positioning and technique, which typically involves having the client's arm at heart level. Placing the arm above heart level can lead to falsely lower blood pressure readings.

C. Incorrect. While promising more equitable assignments is important, addressing the conflict directly and encouraging collaboration is a more proactive approach.

D. Using the palpatory method, the nurse can feel for the radial pulse while slowly deflating the blood pressure cuff. This helps estimate the systolic blood pressure when Korotkoff sounds are challenging to hear. It provides a rough estimate until clear sounds can be heard and ensures accurate blood pressure measurement.

A. Remove the client's restraint every 4 hr. B. Attach the restraint to the bed's side rails. C. Request a PRN restraint prescription for clients who are aggressive. D. Document the client's condition every 15 min.

Correct Answer is D

Explanation

A. Incorrect. Restraints should be removed and repositioned, and the client's needs assessed at a frequency that follows institutional policies, which might not always be every 4 hours.

B. Incorrect. Restraints should be attached to the bed frame, not the side rails, to minimize the risk of injury.

C. Incorrect. PRN (as needed) restraint prescriptions should be avoided. Restraints should only be used based on specific criteria and under the guidance of a healthcare provider.

D. Correct. When using restraints, it's important to document the client's condition frequently to assess for any potential adverse effects or discomfort.

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A home health nurse is planning care for an older adult client who has vision loss and takes medications throughout the day.
Which of the following actions should the nurse include in the plan?