A nurse on a medical-surgical unit is assisting with the admission of a client who has vision loss. Which of the following actions is the nurse's priority?

Describe the environment to the client.

Instruct the client to use the call light when preparing to ambulate.

Encourage the client to feel the walls with her hands.

Remove clutter from the client's room.

Answer and Explanation

The Correct Answer is D

A. Describe the environment to the client – While important, this is not the priority. Ensuring a safe environment first prevents accidents before familiarizing the client with their surroundings.

B. Instruct the client to use the call light when preparing to ambulate – This promotes safety but does not directly prevent falls or hazards from clutter.

C. Encourage the client to feel the walls with her hands – This might help with orientation, but it is not the safest approach to mobility and may lead to unintended accidents.

D. Remove clutter from the client's room: Safety is the priority when assisting a client with vision loss. Removing clutter minimizes the risk of falls and injuries, ensuring a safer environment. A well-organized space allows the client to navigate more confidently

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Correct Answer is B

Explanation

A. Dry, sterile:
A dry dressing does not protect or maintain moisture for a Stage I pressure injury. It can allow further skin breakdown from friction.

B. Transparent:
A transparent film dressing protects from shear, friction, and contamination while allowing moisture retention and wound observation. This is ideal for Stage I pressure injuries.

C. Wet-to-dry:
This is typically used for mechanical debridement, appropriate for wounds with necrotic tissue, not for Stage I, where skin is intact.

D. Antimicrobial:
Antimicrobial dressings are used when infection is present or suspected, which is not typical in an early-stage (non-blistered) pressure ulcer.

A. Encourage regular use of the incentive spirometer. B. Encourage coughing and deep breathing. C. Encourage the client to ambulate more often. D. Encourage the client to drink more fluids.

Correct Answer is D

Explanation

A. Encourage regular use of the incentive spirometer. While important for lung expansion and preventing atelectasis, it does not thin secretions.

B. Encourage coughing and deep breathing. This helps clear secretions but does not thin them.

C. Encourage the client to ambulate more often. Ambulation promotes lung expansion but is not the primary method to thin secretions.

D. Encourage the client to drink more fluids. Hydration helps thin mucus, making it easier to expectorate and improving respiratory function.

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A nurse on a medical-surgical unit is assisting with the admission of a client who has vision loss. Which of the following actions is the nurse's priority?

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