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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Free Nursing Study Resources

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

Explanation

Choice A Reason:

Providing a bed bath is a task that can be delegated to unlicensed assistive personnel (UAP). This task is routine and does not require clinical judgment or advanced nursing skills. UAPs are trained to perform basic care activities such as bathing, which helps maintain the client’s hygiene and comfort.

Choice B Reason:

Assisting in toileting is another task that can be delegated to UAPs. This task involves helping clients with their toileting needs, which is within the scope of practice for UAPs. It does not require the clinical judgment or assessment skills that are reserved for licensed nurses.

Choice C Reason:

Evaluating the effectiveness of a treatment is a task that cannot be delegated to UAPs. This task requires clinical judgment and the ability to assess the client’s response to treatment, which are responsibilities of licensed nurses. Only licensed nurses have the training and expertise to evaluate treatment outcomes and make necessary adjustments.

Choice D Reason:

Assessment of a stoma is a task that cannot be delegated to UAPs. Assessing a stoma involves evaluating its appearance, function, and any signs of complications, which requires clinical judgment and expertise. This task is within the scope of practice for licensed nurses, who are trained to perform comprehensive assessments.

Choice E Reason:

Discharge teaching is a task that cannot be delegated to UAPs. Discharge teaching involves providing clients with important information about their care after leaving the healthcare facility, including medication instructions, follow-up appointments, and lifestyle modifications. This task requires clinical knowledge and the ability to educate clients effectively, which are responsibilities of licensed nurses.

Correct Answer is ["0.4"]

Explanation

Step-by-Step Calculation

Step 1: Identify the desired dose and the concentration of the medication.

Desired dose = 4 mg

Concentration = 10 mg/mL

Step 2: Set up the calculation to find the volume to administer.

Volume to administer (mL) = Desired dose (mg) ÷ Concentration (mg/mL)

Step 3: Perform the division.

4 mg ÷ 10 mg/mL = 0.4 mL

Step 4: Round the answer to the nearest whole number.

0.4 mL rounded to the nearest whole number is 0 mL

Step 5: Apply the instruction to use a leading zero if it applies and do not use a trailing zero.

The final volume to administer is 0.4 mL.

Therefore, the nurse should administer 0.4 mL of furosemide via IV bolus to the client.

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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

The nurse is providing education to a student nurse regarding delegation. What tasks would be unable to be delegated to unlicensed assistive personnel (UAP)? (Select all that apply)

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

Explanation

A nurse is preparing to administer furosemide 4 mg via IV bolus to a client. The amount available is furosemide 10 mg/mL. How many mL should the nurse administer per dose (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.4"]

Explanation

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