The nurse prepares to assess the patient's cranial nerves. Which tool is necessary to assess cranial nerve (CN) III (oculomotor)?
Otoscope
Penlight
Cotton ball
Lavender
The Correct Answer is B
A. An otoscope is used to examine the ear canal and tympanic membrane, not to assess cranial nerve III. This tool is more relevant for assessing cranial nerve VIII (vestibulocochlear), which is responsible for hearing and balance.
B. A penlight is used to assess CN III (oculomotor) by evaluating the pupil's response to light and the ability to move the eye. This nerve controls most of the eye's movements, including constriction of the pupil in response to light.
C. A cotton ball is used to test the sensory function of cranial nerve V (trigeminal), which is responsible for facial sensation. It is not used for assessing CN III.
D. Lavender or other scents may be used to test CN I (olfactory), responsible for the sense of smell, but it is not related to CN III, which governs eye movements and pupil reactions.
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Correct Answer is C
Explanation
A. While administering a narcotic analgesic may be necessary for pain management, it does not address the immediate post-operative needs related to respiratory function and mobility.
B. Encouraging a low-fat diet is important after a cholecystectomy, but this can be addressed after ensuring the client's respiratory function and mobilization are stable.
C. Encouraging the use of the incentive spirometer is the priority intervention as it promotes lung expansion, reduces the risk of atelectasis, and improves oxygenation, which is crucial in the post-operative period.
D. While ambulating the client is important for recovery and preventing complications such as deep vein thrombosis, it should follow ensuring that the patient is able to effectively use the incentive spirometer to maintain respiratory function first.
Correct Answer is B
Explanation
A. 1500: This is incorrect
B. The calculation is as follows:
Remaining fluid: 600 mL
IV rate: 100 mL/hour
Time to empty the bag: 600 mL ÷ 100 mL/hour = 6 hours
Adding 6 hours to the report time:
0700 + 0600 = 1300
The correct answer is 1300.
C. 1400: This is incorrect
D. 1500: This is incorrect