Page 1966 - Saunders Comprehensive Review For NCLEX-RN

vertigo?
1. Increase sodium in the diet.
2. Avoid sudden head movements.
3. Lie still and watch the television.
4. Increase fluid intake to 3000 mL a day.
692. The nurse is preparing to test the visual acuity of a client, using a Snellen
chart. Which identifies the accurate procedure for this visual acuity test?
1. The right eye is tested, followed by the left eye, and then both
eyes are tested.
2. Both eyes are assessed together, followed by an assessment of the
right eye and then the left eye.
3. The client is asked to stand at a distance of 40 feet (12 meters)
from the chart and to read the largest line on the chart.
4. The client is asked to stand at a distance of 40 feet (12 meters)
from the chart and to read the line that can be read 200 feet (60
meters) away by an individual with unimpaired vision.
693. A client’s vision is tested with a Snellen chart. The results of the tests are
documented as 20/60. What action should the nurse implement based on this
finding?
1. Provide the client with materials on legal blindness.
2. Instruct the client that he or she may need glasses when driving.
3. Inform the client of where he or she can purchase a white cane
with a red tip.
4. Inform the client that it is best to sit near the back of the room
when attending lectures.
694. The nurse is caring for a hearing-impaired client. Which approach will
facilitate communication?
1. Speak loudly.
2. Speak frequently.
3. Speak at a normal volume.
4. Speak directly into the impaired ear.

Answers

676. Answer: 1

Rationale: Severe pain or pain accompanied by nausea following a cataract
extraction is an indicator of increased intraocular pressure and should be reported to
the surgeon immediately. Options 2, 3, and 4 are inappropriate actions.
Test-Taking Strategy: Note the strategic word, initial, and the word severe.
Eliminate option 2 because this is not a normal condition. The client should not be
turned to the operative side; therefore, eliminate option 3. From the remaining
options, focusing on the strategic word will direct you to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Complex Care: Emergency Situations/Management

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