A nurse is assessing a client's internal eye structures with an ophthalmoscope. Which of the following actions should the nurse take?

Position the examination light toward the client's face.

Stand on the right side of the client when examining the left eye.

Dim the lights in the room prior to the examination.

Place the ophthalmoscope directly against the client's forehead.

Answer and Explanation

The Correct Answer is B

A. The examination light of the ophthalmoscope should be directed toward the client's eye, not the client's face.

B. When examining the left eye, the nurse should stand on the right side of the client to facilitate proper alignment of the ophthalmoscope with the client's eye.

C. Dimming the lights in the room may improve visualization of the client's internal eye

structures, but it is not typically necessary for ophthalmoscopic examination and may hinder the nurse's ability to assess the client effectively.

D. Placing the ophthalmoscope directly against the client's forehead would not facilitate proper examination of the internal eye structures and may cause discomfort to the client.

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Correct Answer is D

Explanation

A. Portable suction may be needed for some infants but is not specifically indicated for tetralogy of Fallot.

B. A cervical collar is used for neck support in patients with suspected cervical spine injuries and is not indicated for tetralogy of Fallot.

C. A hemodialyzer is used for renal replacement therapy and is not indicated for tetralogy of Fallot.

D. A pulse oximeter is essential for monitoring oxygen saturation levels in infants with tetralogy of Fallot, as they may experience cyanosis and hypoxemia. Monitoring oxygen saturation helps guide interventions and management.

A. Diminished bowel sounds B. Bradycardia C. Hypotension D. Bounding pulses

Correct Answer is D

Explanation

A. Diminished bowel sounds are not typically indicative of fluid overload. They may suggest decreased gastrointestinal motility, but this finding alone does not specifically indicate fluid overload.

B. Bradycardia is not typically associated with fluid overload. Instead, tachycardia may occur as the body attempts to compensate for decreased cardiac output.

C. Hypotension may occur with fluid overload in severe cases, but it is not a consistent or specific finding. Other signs, such as bounding pulses, are more indicative of fluid overload.

D. Bounding pulses, or strong and forceful arterial pulses, can be a sign of fluid overload due to increased blood volume. This finding may be observed in clients receiving excessive enteral feedings or intravenous fluids.

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A nurse is assessing a client's internal eye structures with an ophthalmoscope. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning the discharge of an infant who has tetralogy of Fallot. The nurse anticipates the need for which of the following equipment?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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