While performing a routine assessment of a bedfast client who has bilateral cataracts, the practical nurse (PN) observes that the client's pupils appear milky white. Which action should the PN take next?

Ask the client about any changes in vision.

Notify the charge nurse of the finding.

Assist the client to a semi-Fowler's position.

Assess the client using the Glasgow Coma Scale.

Answer and Explanation

The Correct Answer is B

Choice A reason: Asking the client about any changes in vision can provide valuable information regarding the client's subjective experience and any potential progression of cataracts. However, given the observation of milky white pupils, which may indicate a more serious issue such as advanced cataracts or another underlying condition, it is crucial to take immediate and appropriate action. While gathering subjective data is important, notifying the charge nurse ensures that the finding is promptly addressed by the healthcare team.
Choice B reason: Notifying the charge nurse of the finding is the most appropriate action in this scenario. The observation of milky white pupils in a client with cataracts could indicate significant changes or complications that require further evaluation and potential intervention. By promptly reporting this finding to the charge nurse, the practical nurse ensures that the client receives timely and appropriate care, including potential diagnostic tests and consultations with specialists if necessary.
Choice C reason: Assisting the client to a semi-Fowler's position can be beneficial for comfort and to facilitate breathing, especially in bedfast clients. However, this action does not directly address the observation of milky white pupils. The immediate priority is to notify the charge nurse to ensure that the finding is properly evaluated and managed. Positioning the client can be done as part of routine care, but it is not the most urgent response to the observed change.
Choice D reason: Assessing the client using the Glasgow Coma Scale (GCS) is appropriate for evaluating the level of consciousness and neurological status. However, in this context, the observation of milky white pupils is more likely related to an ocular condition rather than a neurological issue. While it is always important to monitor the client's overall status, the immediate priority is to report the finding to the charge nurse for appropriate ocular assessment and management.

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Correct Answer is A

Explanation

Choice A reason: Coughing over the catheter site while cleansing the skin introduces a risk of infection. The client needs to be educated about the importance of maintaining a sterile environment to avoid contamination and infection. This behavior indicates a lack of understanding of infection control practices, which are crucial in peritoneal dialysis self-care.
Choice B reason: Wearing one sterile glove while cleansing the insertion site may seem insufficient, but it is not as immediately critical as coughing over the site. The client should be reminded of the importance of using sterile techniques, but this behavior does not pose as immediate a risk as choice A.
Choice C reason: Washing hands before opening the 4 by 4 dressing packet demonstrates good hygiene practices. This behavior indicates that the client understands the importance of hand hygiene in preventing infection, and does not require additional teaching.
Choice D reason: Pouring antiseptic solution and sterile water on sterile dressings is an appropriate practice. This behavior shows that the client is following the necessary steps to maintain a sterile environment and does not need additional teaching.

A. Have someone hold the weights up during transport. B. Prevent movement of the weights by resting them on top of the bed until the transport is completed. C. Release the weights during transport and reconnect them when the transport is completed. D. Leave the weights in place during transport.

Correct Answer is D

Explanation

Choice A reason: Having someone hold the weights up during transport is not recommended. Buck's traction relies on the consistent pull of the weights to maintain the proper alignment of the fracture. Holding the weights during transport would disrupt the continuous traction and could cause misalignment or exacerbate the injury. It is crucial to maintain the integrity of the traction system during transport.
Choice B reason: Preventing movement of the weights by resting them on top of the bed until the transport is completed is also not advisable. This action would negate the purpose of the traction by removing the continuous pull required to keep the fracture immobilized. Resting the weights on the bed would result in a loss of traction, potentially leading to complications in the healing process.
Choice C reason: Releasing the weights during transport and reconnecting them when the transport is completed is not appropriate. Temporarily removing the traction could cause significant discomfort to the client and disturb the alignment of the fracture. The stability provided by continuous traction is essential for the proper healing of the fracture, and interruptions can lead to adverse outcomes.
Choice D reason: Leaving the weights in place during transport is the best practice. Buck's traction is designed to provide a consistent and gentle pulling force to maintain the alignment of the fracture. The weights should remain in place to ensure the traction is effective throughout the transport process. Proper care should be taken to handle the traction system carefully and avoid any jarring movements that could impact the client's condition.

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While performing a routine assessment of a bedfast client who has bilateral cataracts, the practical nurse (PN) observes that the client's pupils appear milky white. Which action should the PN take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is assisting a client who is performing peritoneal dialysis catheter self-care before being discharged home. Which behavior indicates that the client needs additional teaching?

Correct Answer is A

Explanation

A client with a fractured femur is placed in Buck's traction to immobilize the fracture. When transporting this client to another room, how should the practical nurse (PN) handle the traction?

Correct Answer is D

Explanation

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