The nurse is assessing a patient’s visual acuity using a Snellen chart. The patient states he cannot see the top of the chart.
What action should the nurse take?

Document findings

Determine whether the patient can count fingers

Obtain a tumbling E chart to assess visual acuity

Complete an internal eye exam .

Answer and Explanation

The Correct Answer is B

Choice B rationale
If a patient states that he cannot see the top of the Snellen chart, the nurse should determine whether the patient can count fingers. If the patient is unable to read the top line of the Snellen

chart at 6 meters, the nurse can reduce the distance to 3 meters from the Snellen chart. If the patient still cannot read the chart, the nurse can then determine whether the patient can count fingers.
Choice A rationale
While documenting findings is an important part of the nursing process, it would not be the immediate action the nurse should take if a patient cannot see the top of the Snellen chart.
Choice C rationale
Obtaining a tumbling E chart to assess visual acuity could be considered if the patient is unable to read letters or numbers, but it would not be the immediate action the nurse should take if a patient cannot see the top of the Snellen chart.
Choice D rationale
Completing an internal eye exam would not be the immediate action the nurse should take if a patient cannot see the top of the Snellen chart.

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Correct Answer is A

Explanation

Choice A rationale
Maintaining a patent airway is the highest priority when providing care for a patient in status epilepticus. Status epilepticus is a medical emergency characterized by prolonged or recurrent seizures. It can lead to severe complications, including respiratory distress and hypoxia.
Therefore, ensuring a patent airway is crucial to prevent hypoxia and further brain damage. This involves positioning the patient to prevent aspiration, potentially suctioning the airway, and providing supplemental oxygen as needed.
Choice B rationale
While placing an intravenous catheter (IV) is an important intervention, it is not the highest priority. An IV allows for the administration of medications and fluids, which are necessary in the management of status epilepticus. However, it is secondary to maintaining a patent airway.
Choice C rationale
Administering diazepam or other antiepileptic drugs is a key intervention in managing status epilepticus. These medications help to stop the seizures. However, medication administration should only occur after a patent airway has been established.
Choice D rationale
Inserting a nasogastric tube (NG) may be necessary in some cases to protect the airway or for administering medications or nutrition. However, this is not the highest priority intervention. The first step in managing status epilepticus is always to ensure a patent airway.

A. Antibiotic therapy B. Antiemetics C. Analgesics D. Antiviral therapy

Correct Answer is A

Explanation

Choice A rationale
If a patient is suspected of having meningitis, the provider will likely prescribe antibiotic therapy after reviewing the lab results. Meningitis is often caused by a bacterial infection, and antibiotics are the primary treatment. The specific antibiotic prescribed will depend on the type of bacteria causing the infection.
Choice B rationale
Antiemetics are medications that help prevent and treat nausea and vomiting. They are not typically used as the primary treatment for meningitis.
Choice C rationale

Analgesics are medications that relieve pain. While they may be used to help manage symptoms in a patient with meningitis, they are not used to treat the underlying infection.
Choice D rationale
Antiviral therapy may be used if the meningitis is caused by a viral infection. However, most cases of meningitis are caused by bacteria, and antibiotics are the primary treatment.

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The nurse is assessing a patient’s visual acuity using a Snellen chart. The patient states he cannot see the top of the chart. What action should the nurse take?

Nursing Test Bank

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Correct Answer is A

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The nurse is assessing a patient’s visual acuity using a Snellen chart. The patient states he cannot see the top of the chart.
What action should the nurse take?