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 D

Explanation

Answer: (D) Refrigerate the specimen until the time of transport to the laboratory

Rationale:

A) Collect 2 ml of sputum in an emesis basin: While it is important to collect an adequate volume of sputum, using an emesis basin is inappropriate for collecting a specimen for culture and sensitivity. Sputum must be collected in a sterile container to avoid contamination, ensuring the accuracy of the culture results.

B) Instruct the client to rinse with an antiseptic mouthwash prior to specimen collection: Using an antiseptic mouthwash before collecting a sputum specimen is not recommended, as it could contaminate the sample with antiseptic agents, potentially affecting the growth of microorganisms in the culture. The client should rinse with plain water instead.

C) Swab the oropharynx with a sterile swab: Swabbing the oropharynx is more appropriate for collecting a throat culture rather than a sputum specimen. Sputum collection requires the client to expectorate mucus from the lower respiratory tract, not from the oropharynx, to obtain an accurate sample for culture and sensitivity.

D) Refrigerate the specimen until the time of transport to the laboratory: Refrigerating the sputum specimen is crucial to preserve the integrity of the sample and inhibit the growth of contaminants before it is transported to the laboratory. This action helps ensure that the results of the culture and sensitivity test are accurate.

A. Instruct the client to bear down during rectal tube insertion. B. Administer a second enema if results are not clear. C. Assist the client to a right Sims' position D. Insert the rectal tube in the direction of the client's umbilicus.

Correct Answer is C

Explanation

When administering a tap water enema, the client should be assisted to a right Sims position. This position involves lying on the left side with the right knee bent toward the chest.

The other options are not correct because:

a) The client should not bear down during rectal tube insertion.

b) Administering a second enema if results are not clear is not mentioned as a safety precaution.

d) The rectal tube should be inserted in the direction of the sacrum, not the umbilicus.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting a sputum specimen from a client for culture and sensitivity. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is reinforcing discharge teaching with an older adult client's family about safety precautions when administering a tap water enema to the client. Which of the following should the nurse include in the instructions?

Correct Answer is C

Explanation

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