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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. A larger-bore needle (usually 18- to 20-gauge) is recommended for blood transfusions to prevent hemolysis and ensure adequate flow rate.
B. Flushing the tubing with 0.9% sodium chloride ensures that it is primed and free from air or any incompatible solutions before starting the blood transfusion.
C. Vital signs should be checked immediately before, during, and after the transfusion to monitor for adverse reactions.
D. Blood transfusions are typically completed over 2 to 4 hours, depending on the clinical context, to reduce the risk of complications.

A. Facilitate the client's problem-solving skills. B. Establish the responsibilities of the nurse and client. C. Assist the client in expressing alternative behaviors. D. Determine previous coping skills used by the client.

Correct Answer is B

Explanation

A: Facilitating problem-solving skills is typically more relevant during the working phase of the therapeutic relationship, not the orientation phase.
B: During the orientation phase, establishing clear roles and responsibilities helps set expectations and boundaries for the therapeutic relationship.
C: Assisting the client in expressing alternative behaviors is also more relevant during the working phase when exploring and implementing change.
D: Determining previous coping skills is important but typically occurs during the assessment phase, which precedes the orientation phase of the therapeutic relationship.

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A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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