The nurse in the family practice clinic is educating a newly graduated nurse on how to correctly use a penlight. The nurse creates the expected outcome: After the review session, the newly graduated nurse will verbalize appropriate penlight examination techniques.

For each statement below, click to specify whether it indicates the outcome was met or not met.

I will confirm the patient's pupil size with the scale on the side of the penlight.

When putting the penlight at the bridge of the nose, the eyes converge and constrict

I will check the patient's pupillary reflex by shining a light into their eyes.

When shining the penlight into the patient's eyes, their pupils should dilate

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

New Nurse Statement	Met	Not Met
I will confirm the patient's pupil size with the scale on the side of the penlight.	✅
When putting the penlight at the bridge of the nose, the eyes converge and constrict	✅
I will check the patient's pupillary reflex by shining a light into their eyes.	✅
When shining the penlight into the patient's eyes, their pupils should dilate		✅

Rationale:

"I will confirm the patient's pupil size with the scale on the side of the penlight" (Met):

This is a correct use of the penlight to assess pupil size and document findings accurately.

"When putting the penlight at the bridge of the nose, the eyes converge and constrict" (Met):

This statement describes the normal accommodation reflex, where the eyes converge and pupils constrict when focusing on a near object.

"I will check the patient's pupillary reflex by shining a light into their eyes" (Met):

This correctly describes testing for the pupillary light reflex, where the pupil constricts in response to light.

"When shining the penlight into the patient's eyes, their pupils should dilate" (Not Met):

This is incorrect. The pupils should constrict in response to light, not dilate. Dilation occurs in response to low light or sympathetic stimulation.

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Correct Answer is C

Explanation

A. Determine areas of tenderness: While identifying tenderness is important, it is not the reason for auscultating first.

B. Allows the patient to relax: Relaxation is helpful but not the primary reason for the sequence.

C. Prevents distortion of bowel sounds: Percussion and palpation can stimulate or suppress bowel sounds, leading to inaccurate findings if performed before auscultation.

D. Prevents distortion of vascular sounds: Vascular sounds (bruits) are less likely to be affected by percussion or palpation.

A. High-pitched, tinkling sounds B. Normal bowel sound C. Hypoactive bowel sounds D. Hyperactive bowel sounds

Correct Answer is C

Explanation

A. High-pitched, tinkling sounds: These may indicate bowel obstruction, not expected immediately after surgery.
B. Normal bowel sounds: Normal bowel sounds usually return gradually after surgery, but are unlikely within the first 24 hours.
C. Hypoactive bowel sounds: It is common to hear hypoactive or diminished bowel sounds in the first 24-48 hours after abdominal surgery due to postoperative ileus.
D. Hyperactive bowel sounds: These suggest increased peristalsis and are not typical immediately after surgery.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

Correct Answer is C

Explanation

A patient had abdominal surgery yesterday when auscultating his abdomen, you would expect to hear:

Correct Answer is C

Explanation

A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a:

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. How long should the nurse listen before reporting absent bowel sounds?

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal?

When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. Next, the nurse should;

During an eye examination, a client tells a nurse that their left eye feels dry and itchy and has noticed a lot of tearing. The nurse notices that the client's left lower eyelid is rolled out with exposure of the palpebral conjunctiva. The nurse would document these findings as:

During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing: