A nurse is preparing to assess a client. Which action should the nurse take to check cranial nerve VI?

Open the client’s visual acuity using a Snellen chart.

Whisper none of the client’s ears while blocking the other.

Ask the client to inspect up.

Ask the client to smile.

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Open the client’s visual acuity using a Snellen chart is incorrect. This action assesses cranial nerve II (optic nerve), which is responsible for vision. The Snellen chart is used to measure visual acuity, not the function of cranial nerve VI

Choice B Reason:

Whisper none of the client’s ears while blocking the other is incorrect. This action assesses cranial nerve VIII (vestibulocochlear nerve), which is responsible for hearing and balance. Whispering tests the auditory function of this nerve.

Choice C Reason:

Ask the client to inspect up is correct. Cranial nerve VI (abducens nerve) controls the lateral rectus muscle, which is responsible for moving the eye outward. Asking the client to look up and outward helps assess the function of this nerve.

Choice D Reason:

Ask the client to smile is incorrect. This action assesses cranial nerve VII (facial nerve), which controls the muscles of facial expression. Smiling tests the motor function of this nerve.

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Correct Answer is C

Explanation

Choice A Reason:

Place suction equipment at the bedside is incorrect. While having suction equipment available is important for emergency situations, it does not directly prevent postoperative pulmonary complications. Suction equipment is used to clear the airway if the client has difficulty breathing or if there is an obstruction.

Choice B Reason:

Administer a prophylactic expectorant is incorrect. Prophylactic expectorants can help in managing secretions, but they are not the primary intervention for preventing postoperative pulmonary complications. The main goal is to promote lung expansion and prevent atelectasis.

Choice C Reason:

Encourage the use of an incentive spirometer is correct. Using an incentive spirometer encourages deep breathing and lung expansion, which helps prevent atelectasis and other postoperative pulmonary complications. It is a key intervention in postoperative care to maintain optimal lung function.

Choice D Reason:

Perform range of motion exercises is incorrect. While range of motion exercises are important for preventing musculoskeletal complications and promoting circulation, they do not directly prevent pulmonary complications. The focus for pulmonary health is on lung expansion and clearing secretions.

A. Loperamide should not be used if diarrhea is infectious. B. You can take loperamide until the diarrhea stops. C. Loperamide has no side effects. D. Loperamide should not stop this type of diarrhea.

Correct Answer is A

Explanation

Choice A Reason:

Loperamide should not be used if diarrhea is infectious is correct. Loperamide is an antidiarrheal medication that works by slowing down gut movement. However, if the diarrhea is caused by an infection, such as from spoiled food, it is important to allow the body to expel the infectious agents. Using loperamide in such cases can prolong the infection and potentially worsen the condition.

Choice B Reason:

You can take loperamide until the diarrhea stops is incorrect. While loperamide can be effective for non-infectious diarrhea, it is not recommended for infectious diarrhea. Stopping the diarrhea prematurely can trap the infectious agents in the intestines, leading to more severe symptoms.

Choice C Reason:

Loperamide has no side effects is incorrect. Loperamide can have side effects, including constipation, dizziness, and abdominal pain. It is important to use this medication under the guidance of a healthcare provider, especially in cases of infectious diarrhea.

Choice D Reason:

Loperamide should not stop this type of diarrhea is incorrect. While it is true that loperamide should not be used for infectious diarrhea, the statement is misleading. Loperamide can stop diarrhea, but it is not appropriate for all types of diarrhea, particularly those caused by infections.

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A nurse is preparing to assess a client. Which action should the nurse take to check cranial nerve VI?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a postoperative client. Which intervention should the nurse identify as important to prevent postoperative pulmonary complications?

Correct Answer is C

Explanation

A nurse is caring for a client with numerous episodes of watery diarrhea. The client reports eating some spoiled deli meat earlier in the day. The client asks if they should take loperamide (Imodium) to stop the diarrhea. What would be an appropriate response from the nurse?

Correct Answer is A

Explanation

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