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. Adjusting the straps on the harness once per week is not recommended. The straps should only be adjusted by a healthcare provider to ensure proper fit and alignment, as incorrect adjustments can compromise the effectiveness of the treatment.

B. Using ultra-thin diapers applied over the straps is incorrect. Diapers should be placed under the harness to prevent soiling and maintain the harness's effectiveness. Placing diapers over the straps can interfere with proper positioning.

C. Maintaining the child in a prone position while the harness is in place is not necessary. The Pavlik harness is designed to keep the hips in a flexed and abducted position, and the infant can remain in various positions that are comfortable and safe.

D. Gently massaging the skin under the straps once per day is correct. This helps prevent skin irritation and promotes circulation. Guardians should also check for redness or irritation and ensure the harness fits properly to avoid pressure injuries.

A. Set up the sterile field 7.6 cm (3 in) below waist level. B. Hold the bottle of sterile solution with the palm over the label while pouring. C. Place the sterile items within 1 cm (0.4 in) of the edge of the sterile border. D. Place the lid of a bottle of sterile solution within the sterile field.

Correct Answer is C

Explanation

A. Set up the sterile field 7.6 cm (3 in) below waist level - While it's important to maintain a sterile field, the specific height mentioned is not a standard requirement.

B. Hold the bottle of sterile solution with the palm over the label while pouring - This is

incorrect because it increases the risk of contaminating the solution by touching the label.

C. Place the sterile items within 1 cm (0.4 in) of the edge of the sterile border - This is the correct action as it ensures that sterile items are easily accessible without reaching over the sterile field, minimizing the risk of contamination.

D. Place the lid of a bottle of sterile solution within the sterile field - Placing the lid inside the sterile field increases the risk of contamination, as the lid is not considered sterile.

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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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