Nokea
The clinic nurse is planning to assess the visual acuity of a 6-year-old. Which method is the best way to assess visual acuity in this child?
- A. Have the child identify different objects using Allen figure testing cards
- B. Have the child point in the direction each letter is facing on a tumbling E chart
- C. Have the child read letters on a Snellen chart while standing 10 ft (3 m) away
- D. Have the child view a set of Ishihara colored cards one at a time
Correct Answer: B
Rationale: The tumbling E chart (B) is age-appropriate for a 6-year-old, who may not know letters. Allen cards (A) are for younger children, Snellen at 10 ft (C) is non-standard, and Ishihara (D) tests color vision.
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The graduate nurse (GN) is caring for a client with a fractured femur in balanced suspension skeletal traction. Which action by the GN will require the precepting nurse to intervene?
- A. Encourages the client to drink plenty of water and choose high-fiber foods from the diet menu
- B. Lifts the traction weights while the unlicensed assistive personnel provide a bed bath and linen change
- C. Monitors the incision and pin insertion sites for erythema, drainage, and malodor
- D. Performs Doppler ultrasound pulse checks in the affected leg every hour for the first 24 hours after surgery
Correct Answer: B
Rationale: Lifting traction weights (B) disrupts alignment and healing, requiring intervention. Hydration and fiber (A), monitoring sites (C), and pulse checks (D) are appropriate.
A 2-year-old who swallowed an overdose of adult cough syrup is being discharged from the emergency department. The parent says to the nurse, 'From now on, I'm going to store all medicines in my top dresser drawer.' Which is the best response by the nurse?
- A. Can you lock your dresser drawer?
- B. Make sure all of your medicines have childproof caps.
- C. That sounds like a safe plan.
- D. You need to keep an eye on your child at all times.
Correct Answer: A
Rationale: A locked drawer (A) ensures safety. Childproof caps (B) are helpful but insufficient alone. The plan (C) is unsafe without a lock, and constant supervision (D) is unrealistic.
The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should the nurse perform first?
- A. Explain that the procedure will help him to get well
- B. Show a cartoon character with a blood pressure cuff
- C. Explain that the blood pressure checks the heart pump
- D. Permit handling the equipment before putting the cuff in place
Correct Answer: D
Rationale: Permit handling the equipment before putting the cuff in place. The best way to gain the toddler's cooperation is to encourage handling the equipment. Detailed explanations are not helpful.
The licensed practical nurse (LPN) is collecting data on several clients in the antepartum unit. Which of the following clients should the LPN report to the registered nurse for further assessment?
- A. 24 weeks gestation, 1-hour glucose screen is 120 mg/dL (6.6 mmol/L)
- B. 25 weeks gestation, hemoglobin is 9 g/dL (90 g/L)
- C. 30 weeks gestation, nonstress test is reactive
- D. 36 weeks gestation, WBC count is 13,000/mm^3 (13 x 10^9/L)
Correct Answer: B
Rationale: Hemoglobin of 9 g/dL (B) indicates anemia, requiring further assessment. Normal glucose (A), reactive nonstress test (C), and slightly elevated WBC (D) are less urgent.
The intensive care nurse is caring for a client who has just been extubated. Which interventions are appropriate at this time?
- A. Administer prescribed oral narcotics for throat pain
- B. Administer warmed, humidified oxygen via facemask
- C. Give the client ice chips to moisten the mouth
- D. Provide mouth care with oral sponges
- E. Start the client on incentive spirometer
Correct Answer: B,C,D,E
Rationale: Post-extubation, warmed, humidified oxygen (B) prevents mucosal drying, ice chips (C) moisten the mouth, oral sponges (D) maintain hygiene, and incentive spirometry (E) promotes lung expansion. Oral narcotics (A) are risky due to potential airway compromise.