Nursing Elites

1. A nurse is preparing to screen a client's vision with the use of a Snellen chart. The nurse uses which technique?

• A. Tests the right eye, then tests the left eye, and finally tests both eyes together
• B. Assesses both eyes together, then assesses the right and left eyes separately
• C. Asks the client to stand 40 feet from the chart and read the largest line on the chart
• D. Asks the client to stand 40 feet from the chart and read the line that can be read 200 feet away by someone with unimpaired vision

Correct answer: A

Rationale: To test visual acuity with the use of a Snellen chart, the nurse places the chart in a well-lit spot at the client's eye level, with the client positioned exactly 20 feet from the chart. The client shields one eye at a time with an opaque card during the test. After testing each eye separately, both eyes are assessed together. The client is asked to read the smallest line of letters visible and encouraged to read the next smallest line as well. Therefore, option A is correct as it describes the correct technique of testing one eye at a time before assessing both eyes together. Option B is incorrect as it assesses both eyes together first, which is not the standard procedure. Options C and D are incorrect as they suggest standing 40 feet from the chart, which contradicts the standard distance of 20 feet for a Snellen chart test.

2. A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment?

• A. Emergency
• B. Follow-up
• C. Complete (total)
• D. Problem-centered

Correct answer: B

Rationale: The correct answer is 'Follow-up.' A follow-up database is used to assess the status of an identified problem at regular intervals. An emergency database is for urgent data collection during life-saving measures. A complete database involves a full health history and physical examination. A problem-centered (episodic) database focuses on a limited or short-term issue, typically centered around one problem or body system.

3. Which of the following methods of contraception is able to reduce the transmission of HIV and other STDs?

• A. intrauterine device (IUD)
• B. Norplant
• C. oral contraceptives
• D. vaginal sponge

Correct answer: D

Rationale: The correct answer is the vaginal sponge. The vaginal sponge is a barrier method of contraception that, when used with foam or jelly contraception, reduces the transmission of HIV and other STDs, as well as reducing the risk of pregnancy. Intrauterine devices (IUDs), Norplant, and oral contraceptives can prevent pregnancy but not the transmission of HIV and STDs. Clients using the contraceptive methods in Choices A, B, and C should be counseled to use a chemical or barrier contraceptive to decrease the transmission of HIV or STDs.

4. A client complains that her skin is redder than normal. The nurse notes the client's skin, documents hyperemia, and explains to the client that this condition is caused by which factor?

• A. Constriction of the underlying blood vessels
• B. An increased amount of bilirubin in the blood
• C. Increased perfusion of the surrounding tissues
• D. Excess blood in the dilated superficial capillaries

Correct answer: D

Rationale: Hyperemia is an excess of blood in a part of the body. The skin over a hyperemic area usually becomes reddened or warm. The condition is caused by increased blood flow, local relaxation of arterioles, or obstruction of the outflow of blood from an area. Choice A is incorrect because constriction of blood vessels would lead to decreased blood flow, not excess blood. Choice B is incorrect as an increased amount of bilirubin in the blood is related to jaundice, not hyperemia. Choice C is incorrect because increased perfusion of the surrounding tissues would cause redness, not hyperemia.

5. A nurse is preparing to auscultate for the presence of bowel sounds in a client who has just undergone surgery. The nurse places the stethoscope in which abdominal quadrant first?

• A. Left upper quadrant
• B. Left lower quadrant
• C. Right upper quadrant
• D. Right lower quadrant

Correct answer: D

Rationale: The correct answer is the right lower quadrant. The nurse starts auscultating in this quadrant at the ileocecal valve as bowel sounds are normally always present there. Then, the nurse proceeds to listen for bowel sounds in the other quadrants. Choices A, B, and C are incorrect as the initial placement of the stethoscope should be in the right lower quadrant to assess bowel sounds post-surgery.

Similar Questions