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A client asks a nurse about their Snellen eye test results. The client's visual acuity is 20/30. Which of the following responses should the nurse make?
- A. "Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet."
- B. "Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet."
- C. "Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet."
- D. "Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet."
Correct Answer: A
Rationale: The correct answer is A: 'Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet.' In the Snellen eye test, a visual acuity of 20/30 means that the client sees at 20 feet what a person with normal vision sees at 30 feet. This indicates that the client's vision is slightly worse than average. Choice B is incorrect as it incorrectly describes the visual acuity of each eye individually, rather than the combined visual acuity. Choice C is incorrect as it misinterprets the meaning of the Snellen eye test results by reversing the values. Choice D is incorrect as it inaccurately describes the visual acuity of the client's eyes, attributing different visual acuities to each eye instead of a combined measurement as indicated by 20/30.
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The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which dinner menu would be best?
- A. Fish sticks, french fries, banana, cookies, milk
- B. Ground beef patty, lima beans, wheat roll, raisins, milk
- C. Chicken nuggets, macaroni, peas, cantaloupe, milk
- D. Peanut butter and jelly sandwich, apple slices, milk
Correct Answer: B
Rationale: The correct answer is B. Ground beef, lima beans, and raisins are rich sources of iron, making this meal plan the most suitable for a child with anemia. Ground beef is a high-iron meat, while lima beans and raisins are also excellent sources of iron. Fish sticks, french fries, banana, and cookies in option A lack sufficient iron content compared to the options in B. Chicken nuggets, macaroni, and peas in option C are not as iron-rich as the ground beef, lima beans, and raisins in option B. Peanut butter and jelly sandwich with apple slices in option D also fall short in providing enough iron when compared to the iron-rich components of option B.
A client is reporting difficulty falling asleep. Which of the following measures should the nurse recommend?
- A. Drink a cup of hot cocoa before bedtime
- B. Exercise 1 hour before going to bed
- C. Use progressive relaxation techniques at bedtime
- D. Reflect on the day's activities before going to bed
Correct Answer: C
Rationale: The correct answer is to recommend the client to use progressive relaxation techniques at bedtime. Progressive relaxation techniques help reduce stress and muscle tension, which can promote better sleep. Choice A, drinking a cup of hot cocoa before bedtime, contains caffeine which can interfere with falling asleep. Choice B, exercising 1 hour before going to bed, can stimulate the body and mind, making it harder to fall asleep. Choice D, reflecting on the day's activities before going to bed, may lead to increased mental activity and prevent relaxation, making it difficult to fall asleep.
A client is receiving discharge instructions for using a walker. Which statement indicates an understanding of the teaching?
- A. I will hire someone to trim the tree that hangs low over the stairs of my front porch.
- B. I will avoid using the walker on uneven surfaces.
- C. I will use the walker on stairs for added support.
- D. I will not need to make any changes to my home environment.
Correct Answer: A
Rationale: The correct answer is A because hiring someone to trim low-hanging branches over stairs ensures home safety and reflects an understanding of walker use. This action indicates the client's awareness of potential hazards and the importance of a safe environment for walker use. Choice B is incorrect as avoiding uneven surfaces is a general safety precaution but does not directly relate to walker use and does not demonstrate an understanding of the teaching. Choice C is incorrect because using a walker on stairs is not recommended due to safety concerns such as balance and fall risks. Choice D is incorrect as making no changes to the home environment may pose safety risks when using a walker, showing a lack of understanding regarding safety precautions needed for walker use.
When assisting an older adult client with dysphagia following a CVA during mealtime, what should the nurse prioritize?
- A. Offer the client tart or sour foods.
- B. Ensure the client is sitting upright while eating.
- C. Provide soft and easily swallowable foods.
- D. Give the client thickened liquids to help with swallowing.
Correct Answer: B
Rationale: The correct answer is to ensure the client is sitting upright while eating. This position helps prevent aspiration and facilitates swallowing. Offering tart or sour foods (Choice A) may not be suitable for someone with dysphagia as they can be difficult to swallow and may increase the risk of aspiration. Providing soft and easily swallowable foods (Choice C) is crucial for individuals with swallowing difficulties. While giving thickened liquids (Choice D) is a common intervention for dysphagia, the priority during mealtime should be ensuring the client's proper positioning to support safe swallowing and prevent aspiration.
Postoperatively, signs of hemorrhagic shock are observed. The nurse notifies the surgeon, who instructs to continue monitoring vitals every 15 minutes and report back in one hour. What should the nurse do next?
- A. Notify the nurse manager
- B. Continue monitoring as instructed
- C. Administer IV fluids as per protocol
- D. Prepare for immediate transfer to the ICU
Correct Answer: B
Rationale: The correct answer is to continue monitoring the patient as instructed. This is crucial to assess the patient's condition and response to initial interventions. Administering IV fluids or preparing for transfer to the ICU should only be done based on further assessment or explicit orders from the healthcare provider. Notifying the nurse manager, as suggested in choice A, without further assessment or intervention could delay immediate patient care and management.