The nurse is preparing to assess the client's eye with an ophthalmoscope while a student nurse is observing. Which of the following statements by the nurse to the student nurse is accurate regarding this portion of the assessment?
1. "I'm going to examine the client's right eye with my left eye.".
2. "I'm going to advance the ophthalmoscope until the instrument touches the client's cornea.".
3. "I'm going to begin with the lens set to the 0 diopter.".
4. "I can see the red reflex as the light reflects off of the client's lens.".
3
Rationale 1: The nurse should prepare to assess the client's eye with an ophthalmoscope by examining the client's right eye with the nurse's right eye.
Rationale 2: The nurse should advance the ophthalmoscope only until it almost touches the client's eyelashes. The cornea contains many nerve endings and this would be painful for the client.
Rationale 3: The nurse should always begin with the lens set to the 0 diopter.
Rationale 4: The red reflex is seen as light reflects off of the client's retina, not his lens.
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