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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Inserting an indwelling catheter involves an invasive procedure and assessment of urinary output and client status, which falls within the RN’s scope of practice in a high-risk client such as one with acute liver failure.
B. Obtaining abdominal girth requires assessment skills and interpretation for changes in ascites, which is more appropriate for the RN to ensure accurate monitoring.
C. Assessing and documenting level of consciousness is a critical assessment, especially in liver failure where hepatic encephalopathy is a risk. This is within the RN’s responsibility because changes can be subtle and require immediate intervention.
D. Measuring the amount of gastric drainage every 2 hours is a stable, routine task that follows established parameters and does not require advanced assessment skills. It is within the LPN’s scope and can be safely delegated, with the RN overseeing interpretation of any abnormal findings.
Correct Answer is C
Explanation
A. Performing another internal exam is not the priority at this moment. The priority is assessing fetal well-being.
B. Notifying the client's provider may be necessary, but it is not the immediate priority.
C. Checking the fetal heart rate (FHR) is the priority action to assess fetal well-being after the observed fluid gush, as it could indicate rupture of membranes and potentially fetal distress.
D. Obtaining a pH test of the fluid can be done later for confirmation of rupture of membranes but is not the immediate priority compared to assessing fetal well-being.
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