Nokea
During an ophthalmic assessment, which of the ff are the nurses expected to observe carefully? Choose all that apply
- A. Level of central vision
- B. Pupil responses
- C. External eye appearance
- D. Eye movements
Correct Answer: B
Rationale: The correct answer is B: Pupil responses. During an ophthalmic assessment, observing pupil responses is crucial as it provides information on the function of the cranial nerves and potential neurological issues. Pupil size, shape, symmetry, and reaction to light are key indicators of eye health.
A: Level of central vision - While important, assessing the level of central vision is typically done by the ophthalmologist and not within the scope of the nurse's role in a routine assessment.
C: External eye appearance - Although external eye appearance can give some clues about eye health, it is not as direct and crucial as observing pupil responses.
D: Eye movements - While eye movements can provide information on ocular motor function, it is not as critical as assessing pupil responses in an ophthalmic assessment.
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Which of the following complications can occur if a clotted cannula is aggressively flushed?
- A. A clot can enter the circulation.
- B. An air embolism can enter the circulation.
- C. A painful arterial spasm can occur.
- D. Fluid extravasation into surrounding tissue can occur.
Correct Answer: A
Rationale: The correct answer is A: A clot can enter the circulation. When a clotted cannula is aggressively flushed, the force can dislodge the clot, allowing it to enter the circulation and potentially leading to serious complications such as embolism.
Incorrect choices:
B: An air embolism can enter the circulation - In the context of a clotted cannula, air embolism is less likely compared to a clot entering the circulation.
C: A painful arterial spasm can occur - Arterial spasm is a potential complication but not directly related to flushing a clotted cannula.
D: Fluid extravasation into surrounding tissue can occur - Flushing a clotted cannula may not specifically lead to fluid extravasation, as it is more related to needle dislodgement or improper placement.
What is the best initial action for the nurse to take?
- A. Try to have the client breathe slower or
- B. Give O2 via nasal cannula
- C. Administer sodium bicarbonate
- D. Monitor the client’s fluid balance
Correct Answer: A
Rationale: The correct initial action for the nurse to take is A: Try to have the client breathe slower. This is because the client may be experiencing respiratory distress, and slowing down their breathing can help improve oxygenation. Giving O2 via nasal cannula (B) should be considered if the client's oxygen saturation is low after trying to slow down their breathing. Administering sodium bicarbonate (C) is not the appropriate initial action unless the client is experiencing severe acidosis. Monitoring the client's fluid balance (D) is important but not the best initial action in this scenario where respiratory distress is the concern.
Which finding will alert the nurse that the goal has been met?
- A. Heart rate 78 beats/min on 12/3
- B. Heart rate 78 beats/min on 12/4
- C. Heart rate 80 beats/min on 12/3
- D. Heart rate 80 beats/min on 12/4
Correct Answer: A
Rationale: The correct answer is A because it meets the goal of maintaining a heart rate of 78 beats/min. This specific date ensures the consistency of the heart rate within the desired range. Choices B, C, and D do not align with the goal as they either have a different heart rate or occur on a different date. Therefore, A is the only option that accurately reflects the goal being met on the specified date.
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
- A. Complete the questions in chronological order.
- B. Focus on the patient’s presenting situation.
- C. Make accurate interpretations of the data.
- D. Conduct an observational overview.
Correct Answer: B
Rationale: The correct answer is B because focusing on the patient's presenting situation is the first step in the problem-oriented approach. This allows the nurse to gather relevant data related to the current health issue, which is crucial for identifying the problem and formulating a care plan. Option A is incorrect as chronological order may not prioritize the most critical data. Option C is incorrect as interpretations come after data collection. Option D is incorrect as observation typically follows data collection and analysis. Focusing on the patient's presenting situation ensures efficient and effective data collection for problem-solving.
Which of the following reflects the importance of client-centered care during the evaluation phase?
- A. Evaluating based solely on physician recommendations.
- B. Assessing whether the care plan aligns with the client’s preferences and goals.
- C. Prioritizing institutional policies over client feedback.
- D. Focusing evaluation on measurable clinical outcomes only.
Correct Answer: B
Rationale: The correct answer is B because client-centered care emphasizes involving clients in decision-making. During evaluation, assessing if the care plan aligns with the client's preferences and goals ensures personalized and effective care. This approach enhances client satisfaction, engagement, and outcomes.
Incorrect choices:
A: Not considering the client's input goes against client-centered care principles.
C: Prioritizing institutional policies over client feedback neglects the client's individual needs.
D: Focusing solely on measurable clinical outcomes may not capture the holistic view of the client's well-being.