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 B

Explanation

A. Inserting an indwelling catheter is within the LPN’s scope of practice. However, this task should only be delegated if the nurse has verified the need and obtained a provider’s order. Delegation of this task depends on the facility’s policies and the LPN’s competencies.

B. Obtaining abdominal girth is a routine measurement that can be delegated to an AP. This task does not require clinical judgment, making it unnecessary to assign it to the LPN.

C. Assessing and documenting the level of consciousness requires critical thinking and nursing judgment, which are responsibilities of the registered nurse (RN). This task should not be delegated to the LPN or AP.

D. Measuring the amount of gastric drainage every 2 hours is within the scope of practice for the LPN. This task involves observation and documentation but does not require complex clinical judgment, making it an appropriate delegation for the LPN.

A. 3hr oral glucose tolerance test B. HbA1c C. Fasting blood glucose test D. Urinalysis for ketones

Correct Answer is B

Explanation

A. 3hr oral glucose tolerance test - This test is typically used for diagnosing gestational diabetes or impaired glucose tolerance, not for long-term management.

B. HbA1c - Hemoglobin A1c reflects the average blood glucose levels over the past 2-3 months and is a reliable indicator of long-term glycemic control.

C. Fasting blood glucose test - This provides a snapshot of blood glucose levels at a specific point in time and is not as reliable for assessing long-term glycemic control as HbA1c.

D. Urinalysis for ketones - Urinalysis for ketones is useful for detecting acute complications such as diabetic ketoacidosis but does not reflect long-term management of blood glucose levels.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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