A nurse is assessing a client who is taking losartan.
Which of the following findings should the nurse identify as an adverse effect of this medication?

Choice A rationale

A color-coded wristband, such as yellow, serves as a visual cue to all healthcare staff that a client has an increased risk of falling. This system promotes a universal understanding of the client's needs, allowing all members of the care team to implement appropriate fall prevention measures proactively and consistently, such as providing assistance with ambulation or frequent rounding.

Choice B rationale

The use of physical restraints, such as a restraint around the waist, is a last resort and requires a provider's order. It is not considered a primary fall prevention strategy. Restraints can increase a client's risk of injury and are associated with negative outcomes, including agitation, skin breakdown, and loss of muscle mass. Fall prevention strategies focus on proactive, non-restrictive interventions.

Choice C rationale

Storing personal items in a bathroom, especially on a high shelf, creates a significant fall hazard. The client may overreach or stand on a stool to retrieve items, increasing their risk of losing balance. To prevent falls, all personal items should be kept within easy reach of the client, such as on the bedside table, to minimize unnecessary movement.

Choice D rationale

While keeping some light on is helpful, having overhead lights on at all times can cause glare and create shadows that distort depth perception. This can make it difficult for a client with vision impairments to see potential obstacles. A low-level nightlight is a safer alternative for nighttime visibility, as it minimizes glare and helps maintain a normal sleep-wake cycle. *.

Choice A rationale

Verifying the clarity and color of the eye drops is a critical safety step to ensure the medication has not been compromised. Eye drops should be clear and colorless unless specified otherwise. Any discoloration or particulate matter indicates that the solution may be contaminated or expired and should not be administered, preventing potential harm or infection to the client.

Choice B rationale

Pulling the lower lid down creates a small pocket, or conjunctival sac, which is the proper site for medication administration. This technique prevents the eye drops from immediately flowing out of the eye, allowing for maximum absorption of the medication. It also protects the cornea from direct injury by the applicator, which can be sensitive and easily scratched.

Choice C rationale

Applying gentle pressure to the punctum, the small opening in the corner of the eye, for 30 to 60 seconds after instillation prevents systemic absorption of the medication. This is particularly important for drugs like timolol, a beta-blocker, as systemic absorption can lead to adverse effects on the heart and lungs, such as bradycardia and bronchospasm.

Choice D rationale

Tilting the client's head backward facilitates proper administration by allowing gravity to assist in directing the eye drop into the conjunctival sac. This position also helps to prevent the drop from immediately rolling out of the eye or onto the client's cheek, ensuring the medication is retained in the correct location for therapeutic effect.

Choice E rationale

Administering the prescribed number of drops directly into the conjunctival sac ensures the client receives the correct dosage. The nurse should avoid touching the tip of the dropper to the client's eye or eyelashes to prevent cross-contamination of the bottle. This step is essential for both the therapeutic efficacy and safety of the medication administration. *.