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The nurse is performing a physical assessment. When assessing a client's eyes for accommodation, which of the following actions would the nurse perform?
- A. Bring a penlight from the side of the client's face and briefly shine the light on the pupil.
- B. Ask the client to gaze at a distant object and then at a test object close to them.
- C. Obtain a tuning fork and place it in the middle of the client's forehead.
- D. Have the client stand twenty feet away from a Snellen chart.
Correct Answer: B
Rationale: Accommodation is tested by having the client shift gaze from a distant to a near object, observing pupil constriction and convergence. Penlight tests pupil response, tuning fork tests hearing, and Snellen tests vision.
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The nurse is discussing negligence with a new nurse. Which of the following situations can the nurse use as an example of negligence?
- A. The Unlicensed Assistive Personnel (UAP) fills a water basin with warm water while the client with depression combs their hair.
- B. A nurse transcribes a new medication order: Cholestyramine powder 2 oz bid with wet food or one full glass of water.
- C. The nurse first checks the distal pulses of a client's legs two hours after they have returned from a cardiac catheterization.
- D. The nurse observes a UAP enter the room of a client on contact precautions wearing gloves and a gown.
Correct Answer: NONE
Rationale: None of the options describe negligence, as all reflect appropriate actions or minor procedural variations without harm.
The nurse performs a home safety survey for an individual with epilepsy. Click to specify the findings that require intervention by the nurse
- A. Multiple glass tables in the living room
- B. Multiple feather pillows present on the bed
- C. Padded covers on the edges of countertops
- D. Wall-to-wall carpeting was removed and replaced with scattered rugs on hardwood flooring
- E. Kitchen knives were readily accessible
- F. Client reports using the microwave instead of the stove
- G. Locks on the bathroom door
Correct Answer: A,D,E,G
Rationale: Glass tables, scattered rugs, accessible knives, and bathroom locks pose injury risks during seizures, requiring intervention.
The nurse is observing infection control practices in the nursing unit. Which of the following findings require follow-up? A client with
- A. H. pylori placed on standard precautions.
- B. rotavirus provided a disposable blood pressure cuff.
- C. rubella and their door is kept closed at all times.
- D. influenza ambulating in the hall with a surgical mask.
- E. Legionnaires' disease placed on contact precautions.
Correct Answer: A,E
Rationale: H. pylori requires contact precautions due to fecal-oral transmission, and Legionnaires' disease requires standard precautions, not contact.
The nurse observes a fire in a client's room. The nurse should take which initial action?
- A. Rescue the client
- B. Extinguish the fire
- C. Activate the fire alarm
- D. Place a linen blanket over the fire
Correct Answer: A
Rationale: Per the RACE protocol, rescuing the client is the initial action to ensure safety.
The nurse cares for a client scheduled for spinal surgery in one hour. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe
- A. gentamicin
- B. enoxaparin
- C. hydromorphone
- D. cyclobenzaprine
Correct Answer: B
Rationale: Enoxaparin, a low-molecular-weight heparin, is commonly prescribed preoperatively for spinal surgery to prevent venous thromboembolism due to prolonged immobility. Gentamicin is an antibiotic, hydromorphone is for pain, and cyclobenzaprine is a muscle relaxant, none of which are typically prioritized preoperatively for this purpose.