A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?

Position the client 3 meters (10 feet) away from the chart

Document the largest line the client can read on the chart

Instruct the client to begin the assessment with both eyes open

Begin by testing the client while they are wearing glasses

Answer and Explanation

The Correct Answer is D

To test visual acuity using a Snellen chart, the nurse should have the patient wear glasses or contact lenses if they normally wear them . The patient should stand 20 feet from the chart . The nurse should tell the patient to first cover the right eye, then left eye, and lastly read the chart with both eyes .

The other options are not correct because:

a). The client should be positioned 20 feet away from the chart, not 3 meters (10 feet).

b) The nurse should document the smallest line the client can read accurately on the chart, not the largest line.

c) The nurse should instruct the client to begin the assessment by covering one eye and reading aloud the letters on the chart, beginning at the top and moving toward the bottom

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Correct Answer is C

Explanation

The nurse should inform the family that the client has the right to refuse medication. It is important to

respect the client's autonomy and right to make decisions about their own care.

a) Scheduling the medication at meal times does not address the issue of the client refusing their medication.

b) Requesting that the family talk to the provider about administering the medication by injection may be an option, but it does not address the issue of informed consent.

d) Asking the family what foods the client likes does not address the issue of informed consent and could be seen as a way to deceive the client into taking their medication.

A. Falls asleep 5 minutes after starting a feeding B. Has 3 wet diapers each day. C. Has a bowel movement every other day. D. Makes audible swallowing sounds.

Correct Answer is D

Explanation

The nurse should identify that the newborn is making audible swallowing sounds as an indication that they are breastfeeding eﬀectively. This indicates that the newborn is able to latch onto the breast and transfer milk eﬀectively.

a) Falling asleep 5 minutes after starting a feeding may indicate that the newborn is not getting enough milk.

b) Having 3 wet diapers each day is not enough for a 5-day-old newborn. A newborn should have at least 6 wet diapers per day.

c) Having a bowel movement every other day is not an indication of eﬀective breastfeeding. A breastfed newborn should have at least 3 bowel movements per day.

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