Question

A client sustained a subconjunctival hemorrhage. The presence of which set of symptoms indicate that the client needs to be seen for further evaluation by an ophthalmologist?

Answer 1

Correct Answers:

Acute pain, change in visual acuity, and foreign body sensation.

Rationale :

👁️A subconjunctival hemorrhage is usually a benign condition caused by ruptured small blood vessels under the conjunctiva, often resolving without treatment.

👁️However, if the client develops acute eye pain, visual changes, or a foreign body sensation, it may signal a more serious underlying ocular injury or pathology such as corneal abrasion, globe rupture, or intraocular pressure changes.

👁️These symptoms require urgent evaluation by an ophthalmologist to prevent permanent vision damage.

👁️In contrast, mild redness, itching, or watery discharge usually indicates allergic conjunctivitis, while chronic burning or difficulty focusing often reflects refractive or age-related issues, not emergencies.

👁️Prompt assessment ensures early detection and intervention for sight-threatening complications.

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Answer 2

Correct Answers:

Inform the surgeon about the client's concern.

Rationale :

🩺The nurse’s role in the consent process is to verify that the form is signed and that the client understands the procedure — not to alter the consent form.

🩺If the client expresses that the procedure is incomplete or inaccurate, such as omitting another lipoma, the nurse must notify the surgeon immediately.

🩺Only the surgeon can clarify the surgical details, provide additional explanations, and obtain a new informed consent if another procedure is to be added.

🩺The nurse should not make changes or have the client sign an altered permit, as this would invalidate legal and ethical standards of informed consent.

🩺Ensuring that the consent accurately reflects the intended procedure protects both the client’s autonomy and legal rights.

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Answer 3

Correct Answers:

Digital (photograph) imaging.

Rationale :

📸Digital photographic imaging provides the most accurate, objective, and consistent method to evaluate wound healing and response to treatment over time.

📸Photos allow visual comparison of wound size, color, depth, and tissue condition, which helps track progress or deterioration of pressure injuries.

📸This method also enhances communication among healthcare providers and serves as legal documentation in the client’s medical record.

📸While narrative or diagram documentation can describe wounds, they lack precision and detail compared to digital images.

📸To maintain confidentiality and accuracy, photos must be taken with consent, using facility-approved equipment and securely stored within the electronic health record (EHR).

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Answer 4

Correct Answers:

Client ambulates slowly with a stooped posture and uses a cane.

Rationale :

💎Objective data are observable, measurable findings collected through inspection, palpation, auscultation, or measurement rather than the client’s self-report.

💎Observing that the client walks slowly, has a stooped posture, and uses a cane provides direct, factual evidence of her functional status and mobility limitations due to arthritis.

💎In contrast, the client’s statements or reports from relatives are subjective data because they rely on perception rather than direct observation.

💎Objective findings are crucial for accurately assessing functional ability, monitoring progress, and determining the need for assistive devices or rehabilitation.

💎These observations help guide the nurse in planning individualized care that supports safety and mobility independence.

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Answer 5

Correct Answers:

One finger.

Rationale :

💡To assess extraocular movements (EOMs), the nurse asks the client to follow a moving object, such as one finger or a pen, through the six cardinal fields of gaze.

💡This evaluates the function of cranial nerves III (oculomotor), IV (trochlear), and VI (abducens), which control eye movement.

💡The nurse observes for smooth, coordinated movement of both eyes; any nystagmus or limitation indicates possible neurological or muscular impairment.

💡A Snellen chart assesses visual acuity, a penlight checks pupil reaction and accommodation, and an ophthalmoscope is used to inspect internal eye structures.

💡Using a single finger provides a simple, effective, and accurate method for assessing ocular motor coordination and nerve integrity.

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Answer 6

Correct Answers:

Start the prescribed antibiotic as close to 1000 as possible.

Rationale :

⏰Preoperative antibiotics are given to prevent surgical site infections by ensuring adequate tissue concentrations of the drug at the time of incision.

⏰The antibiotic should be administered within 30 to 60 minutes before surgery begins to achieve optimal prophylactic effectiveness.

⏰Since the surgery time was moved up to 1000, the nurse must adjust and administer the antibiotic as close as possible to the new start time, ensuring it is completed before anesthesia induction.

⏰Holding the antibiotic or sending it to the OR could delay administration, reducing its protective benefit.

⏰Timely administration is a critical safety measure and part of evidence-based surgical infection prevention protocols.

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Answer 7

Correct Answers:

Assess the client's ability to read a Snellen chart from a distance of 20 feet.

Rationale :

👁️ The Snellen chart is the standard tool used to measure visual acuity, determining how well a client can see at a specific distance.

👁️ Legal blindness in most regions is defined as visual acuity of 20/200 or worse in the better eye with corrective lenses, or a visual field of 20 degrees or less.

👁️ Assessing with a Snellen chart from 20 feet away provides objective, measurable data to support or confirm the client’s statement of legal blindness.

👁️ Other techniques, such as ophthalmoscopy, pupillary reaction, or extraocular movement testing, assess eye structure or function but do not measure visual acuity.

👁️ Documenting this finding assists in determining the degree of visual impairment and guiding referrals for low-vision support services.

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Answer 8

Correct Answers:

Replace the soiled dressing.

Rationale :

🩹The nurse’s first action should be to replace the soiled dressing to prevent infection and further tissue breakdown of the stage 3 pressure injury.

🩹Fecal contamination introduces bacteria that can rapidly lead to wound infection and delayed healing, making wound hygiene an immediate priority.

🩹Once the wound is cleaned and redressed using aseptic technique, the nurse can proceed to reassess bowel sounds and evaluate for possible impaction or need for suppository.

🩹Maintaining skin integrity and preventing infection always take precedence when open wounds are exposed to contaminants such as stool or urine.

🩹Proper wound care and prompt response also reduce the risk of sepsis and pressure injury progression.

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Answer 9

Correct Answers:

Direct nursing actions toward reducing risk factors.

Rationale :

🛡️A “high-risk” nursing diagnosis identifies a situation where the client is vulnerable to developing a problem but does not yet exhibit actual signs or symptoms.

🛡️The nurse’s priority is to implement preventive interventions aimed at reducing or eliminating risk factors before the problem develops.

🛡️Examples include turning a bedbound client to prevent pressure ulcers or monitoring glucose in a client at risk for hypoglycemia.

🛡️Documentation and prioritization are important, but the most critical step is prevention through action—addressing the causes that increase risk.

🛡️Effective planning for high-risk problems supports client safety, early intervention, and optimal outcomes.

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Answer 10

Correct Answers:

Throat swab for rapid strep test.

Rationale :

🧫The presence of white exudate on the tonsils accompanied by sore throat and fever is a classic sign of streptococcal pharyngitis (strep throat).

🧫The nurse should obtain a throat swab from the tonsillar area and posterior pharynx to perform a rapid strep antigen test or a throat culture to confirm Group A β-hemolytic Streptococcus infection.

🧫Early identification allows for prompt antibiotic therapy, which helps prevent complications such as rheumatic fever or glomerulonephritis.

🧫Other tests like sputum cultures or biopsies are not indicated for pharyngeal infections, and a WBC count alone cannot confirm the specific pathogen.

🧫Proper specimen collection technique and infection control precautions ensure accurate results and prevent contamination.

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QLexNursing

1 :
A client sustained a subconjunctival hemorrhage. The presence of which set of symptoms indicate that the client needs to be seen for further evaluation by an ophthalmologist?

2 :
The nurse is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client reports the permit should include another lipoma on the right leg. Which action should the nurse implement?

3 :
The nurse is caring for an older adult client who is admitted to a skilled nursing unit for treatment of pressure injuries on the coccyx and heels of both feet. Which documentation method provides the best means of evaluating treatment?

4 :
The nurse is assessing an older adult female client with arthritis in the spine. Which statement best describes objective data regarding the client's level of functioning?

5 :
When assessing a client's extraocular eye movement, which tool should the nurse use?

6 :
A client who is scheduled for surgery at 1100 has a preoperative IV antibiotic scheduled to be administered at 1000. At 0800, the nurse learns that the surgery time has been changed to 1000. Which action should the nurse take?

7 :
A client states, "I am legally blind." Which assessment technique should the nurse use to obtain data to support the client's statement?

9 :
The nurse determines that a client has a potential "high risk" problem. Which is most important for the nurse to do when planning care?

10 :
A client presents to the clinic with a sore throat and fever. While inspecting the client's throat with a penlight, which laboratory specimen should the nurse collect when white exudate is observed on the tonsils?

QLexNursing

1 : A client sustained a subconjunctival hemorrhage. The presence of which set of symptoms indicate that the client needs to be seen for further evaluation by an ophthalmologist?

2 : The nurse is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client reports the permit should include another lipoma on the right leg. Which action should the nurse implement?

3 : The nurse is caring for an older adult client who is admitted to a skilled nursing unit for treatment of pressure injuries on the coccyx and heels of both feet. Which documentation method provides the best means of evaluating treatment?

4 : The nurse is assessing an older adult female client with arthritis in the spine. Which statement best describes objective data regarding the client's level of functioning?

5 : When assessing a client's extraocular eye movement, which tool should the nurse use?

6 : A client who is scheduled for surgery at 1100 has a preoperative IV antibiotic scheduled to be administered at 1000. At 0800, the nurse learns that the surgery time has been changed to 1000. Which action should the nurse take?

7 : A client states, "I am legally blind." Which assessment technique should the nurse use to obtain data to support the client's statement?

9 : The nurse determines that a client has a potential "high risk" problem. Which is most important for the nurse to do when planning care?

10 : A client presents to the clinic with a sore throat and fever. While inspecting the client's throat with a penlight, which laboratory specimen should the nurse collect when white exudate is observed on the tonsils?

1 :
A client sustained a subconjunctival hemorrhage. The presence of which set of symptoms indicate that the client needs to be seen for further evaluation by an ophthalmologist?

2 :
The nurse is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client reports the permit should include another lipoma on the right leg. Which action should the nurse implement?

3 :
The nurse is caring for an older adult client who is admitted to a skilled nursing unit for treatment of pressure injuries on the coccyx and heels of both feet. Which documentation method provides the best means of evaluating treatment?

4 :
The nurse is assessing an older adult female client with arthritis in the spine. Which statement best describes objective data regarding the client's level of functioning?

5 :
When assessing a client's extraocular eye movement, which tool should the nurse use?

6 :
A client who is scheduled for surgery at 1100 has a preoperative IV antibiotic scheduled to be administered at 1000. At 0800, the nurse learns that the surgery time has been changed to 1000. Which action should the nurse take?

7 :
A client states, "I am legally blind." Which assessment technique should the nurse use to obtain data to support the client's statement?

9 :
The nurse determines that a client has a potential "high risk" problem. Which is most important for the nurse to do when planning care?

10 :
A client presents to the clinic with a sore throat and fever. While inspecting the client's throat with a penlight, which laboratory specimen should the nurse collect when white exudate is observed on the tonsils?