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A nurse in the neurology clinic is assessing a patient's eyes for extraocular movements. Which correctly describes the procedure for this test?
- A. Ask the patient to sit about 3 ft away, facing the nurse.
- B. Have the patient follow a penlight held 1 ft from their face slowly through the cardinal positions.
- C. Move a penlight in concentric circular motion in front of the patient's eyes.
- D. Ask the patient to cover one eye with a hand or index card.
Correct Answer: B
Rationale: The steps in testing for extraocular movement are: (1) Ask the patient to sit or stand about 2 ft away, facing the nurse, who is sitting or standing at eye level with the patient; (2) ask the patient to hold the head still and follow the movement of a forefinger or a penlight with the eyes; (3) keeping the finger or light about 1 foot from the patient's face, move it slowly through the cardinal positions of gaze-up and down, left and right, diagonally up and down to the left, diagonally up and down to the right. Option B most accurately describes this procedure.
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The nurse is caring for a patient experiencing bronchospasm due to an exacerbation of asthma. During auscultation, the nurse anticipates the presence of which breath sound?
- A. Sibilant
- B. Wheezes
- C. Rhonchi
- D. Crackles
Correct Answer: B
Rationale: Wheezes are musical or squeaking high-pitched, continuous sounds heard as air passes through narrowed airways, such as with bronchospasm found in asthma or COPD. Rhonchi are low-pitched, continuous sounds with a snoring quality, which may clear with coughing; they occur when air passes through secretions. Crackles are discontinuous bubbling, cracking, or popping, low- to high-pitched sounds, that occur when air passes through fluid in the airways.
A nurse is performing a breast assessment using the circular technique for palpation, gently compressing the breast tissue against the chest wall. How does the nurse proceed with the examination?
- A. Begins at the tail of Spence and moves in increasing smaller circles
- B. Starts at the outer edge of the breast and palpates up and down the breast
- C. Works in a counterclockwise direction and palpates from the periphery toward the areola
- D. Proceeds from the inner edge of the breast and palpates up and down the breast
Correct Answer: A
Rationale: During breast assessment, the nurse palpates each quadrant of the breasts in a systematic method using the pads of the first three fingers to gently compress the breast tissue against the chest wall. In the circular method, the nurse begins at the tail of Spence and moves in increasingly smaller circles. In the wedge method, the nurse works in a clockwise direction and palpates from the periphery toward the areola. In the vertical strip method, the nurse begins at the outer edge of the breast, palpating up and down the breast.
A nurse and AP are caring for a patient who just returned from the operating room after a femoral-popliteal arterial bypass graft. The nurse is getting another admission. What activity can the nurse safely delegate to the AP?
- A. Determining if pedal pulses are present
- B. Evaluating the patient's pain
- C. Reinforcing the sterile dressing
- D. Ordering dressing supplies
Correct Answer: D
Rationale: The nurse can delegate noncomplex activities to the AP such as obtaining (dressing) supplies, bedmaking, bathing, I & O, toileting, and ambulation. The nurse must perform assessments, provide teaching, perform sterile procedures, and develop the care plan.
A school nurse assesses adolescents' visual acuity using a Snellen eye chart. Which explanation does the nurse provide to the student whose vision is 20/40 in both eyes?
- A. They see better than 50% of people.
- B. Double vision is present.
- C. Vision is less than normal.
- D. They have normal vision.
Correct Answer: C
Rationale: Normal vision is 20/20. The higher the denominator indicates increasingly worse vision; 20/40 vision indicates less than normal vision.
When inspecting the skin of a patient who has cirrhosis of the liver, the nurse notes the skin has a yellow tint. What term will the nurse use to document the skin assessment in the electronic health record?
- A. Jaundice
- B. Cyanosis
- C. Erythema
- D. Pallor
Correct Answer: A
Rationale: Jaundice refers to a yellowish skin color caused by liver, gallbladder, or pancreatic diseases. Cyanosis is a bluish skin color caused by a cold environment or decreased oxygenation. Erythema is a reddish color caused by blushing, alcohol intake, fever, injury trauma, or infection. Pallor is a paleness caused by anemia or shock.