A nurse is collecting data from a client who was involved in a motor-vehicle crash.Which of the following techniques should the nurse use to test for corneal reflexes?

Visualize the red reflex of the eye.

Examine the eye with a penlight.

Lightly touch the eye with a wisp of cotton.

instill drops of dye into the eye.

Answer and Explanation

The Correct Answer is C

A.   This is a technique used for assessing the fundus and is not related to corneal reflexes.
B.   This is used for general eye examination but does not specifically test corneal reflexes.
C.   This tests the corneal reflex, where a blink response indicates the reflex is intact.
D.   This is used for assessing corneal abrasions or ulcers but is not a method to test corneal reflexes.

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Correct Answer is D

Explanation

A. The use of an incentive spirometer is more relevant for preventing respiratory complications, not related to the client's low WBC count.
B. Negative-pressure airflow rooms are typically used for clients with airborne infections, not those with low WBC counts.
C. Cooked fruits may be advisable to reduce the risk of bacterial contamination in immunosuppressed clients, but it does not directly address the low WBC count.
D. Reporting temperatures greater than 39.5°C (102.3°F) lasting more than 4 hours is crucial as it may indicate an infection, and prompt intervention is needed in immunosuppressed clients.

A. Use clean technique when changing the catheter dressing. B. Change the catheter dressing every 2 days. C. Clean the access port on the CVAD line with povidone-iodine prior to use D. Perform hand hygiene for 10 sec prior to changing the catheter dressing. E. Use friction when cleaning the access port.

Correct Answer is ["A","D"]

Explanation

A. Using clean technique helps prevent contamination during catheter dressing changes.
B. Changing the catheter dressing every 2 days may not be necessary, and frequency should be based on the facility's policy and the client's condition.
C. Povidone-iodine is not the recommended antiseptic for cleaning the access port.
Alcohol or chlorhexidine is typically recommended.
D. Proper hand hygiene is crucial to prevent introducing pathogens during catheter care.
E. Using friction when cleaning the access port is not a recommended practice and may cause damage. Cleaning should be done gently to avoid compromising the integrity of the site.

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A nurse is collecting data from a client who was involved in a motor-vehicle crash.Which of the following techniques should the nurse use to test for corneal reflexes?

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Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for an older adult client who has a WBC of 2000/mm3 after three rounds of chemotherapy. Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse is assisting in the care of a client. Exhibits The nurse is assisting with catheter care for the client to prevent a central line-associated bloodstream infection (CLABSI bundle). Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["A","D"]

Explanation

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A nurse is assisting in the plan of care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?