Nursing Elites

1. When performing an eye examination, which area can a healthcare provider best visualize using an ophthalmoscope?

• A. Iris
• B. Cornea
• C. Optic disc
• D. Conjunctiva

Correct answer: C

Rationale: An ophthalmoscope is a tool used to visualize the internal structures of the eye during an examination. The optic disc, located on the internal surface of the retina, can be best visualized using an ophthalmoscope. The iris, cornea, and conjunctiva are superficial structures that can be examined without the need for an ophthalmoscope. Therefore, the correct answer is the optic disc. Choices A, B, and D are incorrect because they are external structures that can be examined directly without the use of an ophthalmoscope.

2. During the health screening of an adolescent, which finding by the nurse requires further teaching?

• A. The client started her first menses 2 years ago.
• B. The client states she is currently taking birth control pills.
• C. The client states she recently lost 5 pounds.
• D. The client states she is experiencing growing pains.

Correct answer: B

Rationale: The correct answer is 'The client states she is currently taking birth control pills.' This finding requires further teaching because being on birth control pills does not protect against sexually transmitted diseases (STDs), and the adolescent should be educated on the importance of using barrier methods (e.g., condoms) for STD prevention. Choices A, C, and D are not concerning. Choice A is a normal developmental milestone in adolescence. Choice C could indicate a positive lifestyle change, and choice D is a common complaint during this stage of development.

3. What is the therapeutic range for carbamazepine (Tegretol)?

• A. 7-12 mcg/mL
• B. 4-10 mcg/mL
• C. 10-14 mcg/mL
• D. 1-5 mcg/mL

Correct answer: B

Rationale: The therapeutic range for carbamazepine (Tegretol) is 4-10 mcg/mL. This range is established based on the optimal balance between effectiveness and safety. Choices A, C, and D are outside the therapeutic range for carbamazepine, which could lead to suboptimal treatment outcomes or increased risk of toxicity. Choice B (4-10 mcg/mL) is the correct range recommended for therapeutic efficacy while minimizing adverse effects.

4. A nurse assisting with data collection uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. The nurse makes which determination?

• A. The client has a fever.
• B. The skin temperature is normal.
• C. The client needs to drink additional fluids.
• D. The client needs to have the blanket removed.

Correct answer: B

Rationale: To assess skin temperature, the nurse would first note the temperature of their own hands. Then, using the backs of the hands to palpate the client's skin bilaterally, warmth suggests normal circulatory status if the skin is warm and the temperature is equal bilaterally. The hands and feet may feel slightly cooler in a cool environment. Options A, C, and D are incorrect responses. A warm skin temperature does not indicate a fever, the need for additional fluids, or the need to have the blanket removed.

5. A nurse in the newborn nursery, assisting with data collection for a newborn, prepares to measure the chest circumference. The nurse places the tape measure around the infant at which location?

• A. In the axillary area
• B. At the level of the nipples
• C. Two inches below the nipples
• D. At the level of the umbilicus

Correct answer: B

Rationale: The chest circumference of the infant is measured at the level of the nipples. It is usually 2 to 3 cm smaller than the head circumference. The average chest circumference is 30.5 to 33 cm (12-13 inches). When there is molding of the head, the head and chest measurements may be equal at birth. Placing the tape measure at the level of the nipples ensures accuracy and consistency in newborn assessment. Options A, C, and D are incorrect as the chest circumference is specifically measured at the level of the nipples to obtain precise measurements.

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