A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?

Eyelashes that curl slightly outward.

Eyelids that blink involuntarily 30 to 35 times per minute

Corneas with an opaque appearance

Pupils that are 8 to 9 mm in diameter

Answer and Explanation

The Correct Answer is A

A. Eyelashes that curl slightly outward:

This is the correct answer. The direction and curl of eyelashes vary among individuals, but eyelashes that curl slightly outward are a normal and expected finding. This characteristic does not typically indicate any pathology or abnormality.

B. Eyelids that blink involuntarily 30 to 35 times per minute:

The normal range for involuntary blinking is approximately 15 to 20 times per minute. A rate of 30 to 35 blinks per minute may suggest increased nervousness or anxiety and is not within the expected normal range.

C. Corneas with an opaque appearance:

Normal corneas should have a clear and transparent appearance. Opacity of the cornea can be indicative of various eye conditions, such as corneal edema or scarring, and is not an expected finding in a healthy eye.

D. Pupils that are 8 to 9 mm in diameter:

The normal range for pupil size is approximately 2 to 6 mm in diameter. Pupils that are 8 to 9 mm in diameter may indicate abnormal dilation (mydriasis) and can be associated with conditions such as drug toxicity or neurological issues.

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Correct Answer is B

Explanation

A. Case manager:

The nurse manager, in this context, is not functioning as a case manager. Case management typically involves coordinating and managing the overall care plan for a client over time, including coordination of resources and services.

B. Client care provider:

The nurse manager, in this scenario, is functioning as a client care provider. By observing the newly licensed nurse perform a straight catheterization, the nurse manager is directly involved in overseeing and ensuring the safety of the client care being provided.

C. Client advocate:

While advocacy for the client is a crucial role for all nurses, the specific action described (observing the procedure) is more aligned with the role of a client care provider. Advocacy involves supporting and safeguarding the client's rights and well-being, which can be done in various nursing roles.

D. Client educator:

The nurse manager is not functioning as a client educator in this specific situation. Client education involves providing information and instruction to the client to promote their understanding and participation in their care. The nurse manager's role here is more focused on direct observation and supervision of a clinical skill.

A. Administer the client's medications one at a time. B. Encourage the client to use a straw to take the medications. C. Give the client's medications between meals. D. Assist the client into semi-Fowler's position.

Correct Answer is A

Explanation

A. Administer the client's medications one at a time:

This is the correct action. Administering medications one at a time allows the nurse to monitor the client's ability to swallow each medication safely. It minimizes the risk of aspiration and ensures that each medication is swallowed effectively.

B. Encourage the client to use a straw to take the medications:

Using a straw may not be recommended for clients with dysphagia, as it can alter the normal swallowing process and increase the risk of aspiration. The focus should be on safe administration of medications without compromising the client's ability to swallow.

C. Give the client's medications between meals:

The timing of medication administration is important, but the priority is the safe administration of medications, especially for clients with dysphagia. Administering medications between meals may not directly address the safety concerns related to swallowing.

D. Assist the client into semi-Fowler's position:

While positioning is important, especially for clients with dysphagia, the administration of medications one at a time (Option A) takes precedence in ensuring the safety of the client's swallowing. Semi-Fowler's position may be beneficial, but it is not the primary action related to medication administration.

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A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is the nurse manager functioning?

Correct Answer is B

Explanation

A nurse is caring for a client who has dysphagia and is receiving oral medications. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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