A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply.)
Keep objects in the client's room in the same place.
Approach the client from the side.
Ensure there is high-wattage lighting in the client's room.
Allow extra time for the client to perform tasks.
Touch the client gently to announce presence.
Correct Answer : A,C,D
A. Keeping objects in the same place help maintain a safe environment and independence for a client with vision loss.
B. When caring for a client with vision loss, the nurse should avoid approaching the client from the side since it may startle them.
C. Providing high-wattage lighting can improve visibility for clients with partial vision loss. Adequate lighting reduces shadows and enhances contrast, making it easier for the client to see their surroundings
D. Allowing extra time for tasks helps orient them to the nurse's presence and facilitates communication.
E. While gentle touch can be a way to announce presence, it is better to verbally announce oneself first to avoid startling the client, particularly if they are not expecting contact.
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Related Questions
Correct Answer is B
Explanation
A. This amount of residual is generally considered safe; guidelines often cite higher residuals (e.g., >100 mL) as concerning.
B. Clients with a history of gastroesophageal reflux disease (GERD) are at increased risk for aspiration, particularly when lying flat, because the lower esophageal sphincter may not function properly, allowing stomach contents to move back into the esophagus.
C. While high-osmolarity formulas can contribute to diarrhea, they are not directly linked to an increased risk of aspiration.
D. Sitting in a high-Fowler’s position (semi-upright) during feedings is actually recommended to reduce the risk of aspiration.
Correct Answer is C
Explanation
A. Reevaluating for an ET cuff leak is important but not the immediate priority when the cause of the alarm is unknown, and the client is in distress. It is more important to ensure the client is receiving adequate ventilation.
B. Assessing for disconnected tubing is essential, but if the cause of the high-pressure alarm is unclear and the client is in distress, manual ventilation should take precedence.
C. When a high-pressure alarm sounds on a mechanical ventilator and the cause is not immediately identifiable, the nurse should prioritize the client's safety by delivering breaths manually with a resuscitation bag. This ensures that the client continues to receive oxygen while troubleshooting the ventilator issue. Manual ventilation is crucial in preventing hypoxia during periods of mechanical failure or when the cause of the alarm cannot be quickly identified.
D. Decreasing the ventilator flow rate may not address the underlying issue causing the high-pressure alarm and could potentially worsen the situation. Immediate manual ventilation is the safest action.
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