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
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Elevating the legs helps to reduce swelling and promotes venous return, which is beneficial for a client with phlebitis. This action improves circulation and aids in preventing the formation of blood clots.
Rolls the extra stocking material down to the client's knee: This action is incorrect because elastic antiembolic stockings should be applied evenly and smoothly without any excess material. Rolling down the extra material can create folds and wrinkles, which can compromise the effectiveness of the stockings and potentially cause discomfort or impaired circulation.
Massages the legs before applying the stockings: Massaging the legs before applying antiembolic stockings is not recommended. Massaging can stimulate blood flow and may dislodge any existing blood clots, posing a risk of embolism. It is important to handle the legs gently and avoid any aggressive or manipulative actions that can disturb the clots.
Positions the client in a chair before applying the stockings: Positioning the client in a chair before applying antiembolic stockings is not the correct action. It is preferable to have the client lie flat in a supine position, with the legs elevated, while applying the stockings. Lying flat helps improve venous return and ensures proper alignment and positioning of the stockings.
Correct Answer is C
Explanation
c. Instruct the client to stand up slowly.
Explanation:
The correct answer is c. Instruct the client to stand up slowly.
Prazosin is an alpha-1 adrenergic blocker used to treat hypertension and benign prostatic hyperplasia. One of the common side effects of prazosin is orthostatic hypotension, which can cause a drop in blood pressure when changing positions from lying or sitting to standing.
In this scenario, the client's blood pressure is 100/60 mm Hg, which indicates hypotension. To prevent a sudden drop in blood pressure and related symptoms such as dizziness or fainting, the nurse should instruct the client to stand up slowly. This allows the body time to adjust to the change in position and minimizes the risk of orthostatic hypotension.
Option a, administering a reversal agent, is not necessary in this situation. Reversal agents are used to counteract the effects of specific medications when there is a need to rapidly reverse their actions. There is no indication in the scenario that the client requires a reversal agent.
Option b, initiating cardiac monitoring, is not warranted based solely on a blood pressure reading of 100/60 mm Hg. Cardiac monitoring is typically indicated when there are specific cardiac concerns or symptoms, which are not mentioned in the scenario.
Option d, informing the client to report urinary retention, is a potential side effect of prazosin but is not the most appropriate action to take in this situation. The client's blood pressure is the immediate concern, and addressing orthostatic hypotension by instructing the client to stand up slowly is the appropriate action.
By instructing the client to stand up slowly, the nurse promotes safety and minimizes the risk of orthostatic hypotension, allowing the client to adjust to the change in position and reduce the likelihood of experiencing symptoms related to low blood pressure.
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