Which technique should the nurse use to assess the pupillary reaction on a client?

Ask the client to follow the penlight in six directions and observe for bilateral pupil constriction.

Bring a narrow beam of light from the side of the patient's face and briefly shine the light on the pupil, observing the pupil for constriction.

Hold a finger 6-8 inches from the bridge of the patient's nose and move finger toward the patient's nose to observe pupil's reaction.

Have the client focus on a distant object, then ask the client to look at the penlight being held about 4-6 inches from the nose and observe for pupil constriction.

Answer and Explanation

The Correct Answer is B

: Bring a narrow beam of light from the side of the patient's face and briefly shine the light on the pupil, observing the pupil for constriction. This is the appropriate technique to assess pupillary reaction. The nurse should stand to the side of the patient and use a penlight or other focused light source to illuminate one pupil at a time. The light should be directed from the side of the eye, not directly in front of it, to avoid stimulating the accommodation reflex. The nurse should observe for constriction of the pupil, which should occur in response to the light. This assessment is important because changes in pupil size and reactivity can indicate neurological dysfunction or other medical conditions.

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Correct Answer is ["B","C","D","E"]

Explanation

correct answers are:

B Use standard terminology and commonly used medical abbreviations.

C Factually record the date and time the healthcare provider was notified of a concern and exact healthcare provider response.

D o not document nursing interventions ahead of time before performing them.

E Document nursing interventions performed by the nurse who is documenting.

Nurses play a crucial role in patient care and documentation guidelines are important to ensure accuracy, completeness, and continuity of care. Using standard terminology and commonly used medical abbreviations is important to ensure that documentation is clear, concise, and easily understood by all members of the healthcare team. This practice helps avoid confusion, facilitates communication, and ensures that all healthcare professionals can accurately interpret and act upon the documented information.

Correct Answer is ["0.2"]

Explanation

Each mL contains 5,000,000 units. Therefore, to administer 1,000,000 units, we need:

1,000,000 units / 5,000,000 units/mL = 0.2 mL

So, the nurse will give 0.2 mL of reconstituted penicillin G to the client.

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Which technique should the nurse use to assess the pupillary reaction on a client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A new nurse understands that documentation guidelines are important to ensure accuracy. The nurse would perform which of the following documentation guidelines? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

The physician orders penicillin G 1,000,000 units IM. The label on the vial of powdered penicillin G reads to reconstitute with 1.6 mL of sterile water to achieve a concentration of 5,000,000 units/mL. How many mL will the nurse give to the client for the ordered dose?

Correct Answer is ["0.2"]

Explanation

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